Every finding on record at Valley's Best Hospice, Inc.

Based on  interview, and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure the Condition of Participation (COP-a set of minimum professional standards all hospice agencies must meet to participate in Medicare [federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) for Initial & Comprehensive  Assessment (assessment to identify 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) of Patient was met as follows: --- 1. The Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) staff failed to conduct a complete and accurate assessment of two of 14 sampled patients (Patient 7 and Patient 9) for the current medical conditions and medications by failing to:a.      Ensure the admitting visiting registered nurse (RN) who conducted the initial home visit to admit a patient into a hospice care) assessed Patient 7, who had a diagnosis of type 2 diabetes mellitus (DM II, long-term condition in which the body is unable to maintain normal blood glucose [BG, blood sugar] levels) with a diabetic complication (additional health problem caused by uncontrolled BG levels), for Patient 7’s baseline BG levels and any previous and current antidiabetic medications.b.      Ensure the admitting VN assessed Patient 9, who had Alzheimer’s disease (progressive brain disorder that causes memory loss and decline in mental ability), was bedbound (confined to bed), and had DM II with diabetic complications with a long-standing wound to the coccyx (tailbone), for Patient 9’s baseline BG levels and any previous and current antidiabetic medications.These failures placed Patient 7 and Patient 9 at increased risks for hypoglycemia (dangerously low BG levels, typically below 70 milligrams [mg, unit of weight] per deciliter [dL, unit of volume], that is manifested by shakiness, sweating, dizziness, confusion, seizures, or loss of consciousness) and hyperglycemia (abnormally high BG levels, that can be manifested by blurred vision, confusion, and increased thirst  that can lead to coma) and/or delayed wound healing due to ineffective treatment plan related to possible uncontrolled BG levels (Refer to L524). 2. The HA failed to ensure complete and accurate medication profile reviews (comprehensive assessment of the patient’s medications to identify and resolve any issues to ensure the medications are appropriate and safe for the patient) were conducted for one of 14 sampled patients (Patient 4) by failing to: -Ensure the skilled nurses (SNs) identified the discrepancies and clarified with Patient 4’s physician the medication orders on amlodipine (medication to treat high blood pressure [BP, force of blood pushing against artery walls as the heart pumps]), acetaminophen (medication to treat mild to moderate pain), Dulcolax (medication to treat constipation), and Robitussin (medication to treat cold and cough symptoms) during the medication profile review performed at every home visit.-Ensure Registered Nurse (RN 2) provided an updated list of Patient 4’s medications to include the new physician’s order for Miralax (medication to treat constipation) to Patient 4’s family/caregivers during the home visit on 11/14/2025.These failures had the potential to lead to ineffective drug therapy and adverse drug reactions (harmful, unintended, or unexpected reaction to a medication when taken at normal doses) related to not taking the medications as prescribed by the physician (Refer to L530). 3. The HA failed to ensure the HA licensed nurses conducted and documented complete and accurate ongoing assessments for one of 14 sampled patients (Patient 6) to reflect the patient’s current condition and antidiabetic medications and to ensure the correct treatments and services were provided.This failure had the potential to result in ineffective drug therapy and inappropriate care and services related to inaccurate assessment of Patient 6’s individualized needs (Refer to L533). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with federal regulation for Initial and Comprehensive Assessment of Patient to ensure the highest quality of care was being provided to patients certified to receive the hospice benefits.

Based on interview and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) staff failed to ensure the comprehensive assessments for two of 14 sampled patients (Patient 7 and Patient 9) identified their current medical conditions and medications by failing to:a.      Ensure the admitting visiting Registered nurse (RN) who conducted the initial assessment for Patient 7, who had a diagnosis of type 2 diabetes mellitus (DM II, long-term condition in which the body is unable to maintain normal blood glucose [BG- blood sugar] levels) with a diabetic complication (additional health problems caused by uncontrolled BG levels), identified Patient 7’s baseline BG levels and the previous and current antidiabetic medications as ordered by the physician.b.      Ensure the admitting visiting RN assessed Patient 9, who had Alzheimer’s disease (progressive brain disorder that causes memory loss and decline in mental ability), was bedbound (confined to bed), and had DM II with diabetic complications with a long-standing wound to the coccyx (tailbone) identified Patient 9’s baseline BG levels and the previous and current antidiabetic medications ordered  by the physician.These deficient practices placed Patient 7 and Patient 9 at increased risks for hypoglycemia (dangerously low BG levels, typically below 70 milligrams [mg] per deciliter [dL], that is manifested by shakiness, sweating, dizziness, confusion, seizures, or loss of consciousness) and hyperglycemia (abnormally high BG levels, that can be manifested by blurred vision, confusion, and increased thirst  that can lead to coma) and/or delayed wound healing due to ineffective treatment plan related to possible uncontrolled BG levels. --- Findings:a.      During a review of Patient 7’s profile sheet, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 7’s start of care (SOC) on 11/6/2025 with diagnoses that included Alzheimer’s disease and DM II with diabetic chronic kidney disease (diabetic complication characterized by the damage to the kidneys’ filtering system due to uncontrolled BG levels). During an interview and a concurrent review of Patient 7’s clinical records with the Director of Patient Care Services (DPCS) on 11/17/2025 at 2:37 p.m., Patient 7’s nursing assessments, previous health history, care plans, medication list, and visit notes were reviewed. The DPCS stated there was no documented evidence of any initial assessment and ongoing assessments of Patient 7’s baseline BG levels and DM II monitoring. The DPCS stated Patient 7 currently had no physician orders for any antidiabetic medications. The DPCS stated the assessments must be complete and accurate “to be able to know exactly what’s going on with the patient” and provide the necessary hospice care and services. b.      During a review of Patient 9’s profile sheet, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 9’s SOC on 7/13/2025 with diagnoses that included Alzheimer’s disease, DM II with diabetic cataract (complication of DM II characterized by the clouding of the eye’s lens due to high BG levels) and diabetic polyneuropathy (complication of DM II characterized by nerve damage, oftentimes affecting the legs and feet, due to high BG levels).During a review of Patient 9’s “Visit Note Report – RN Hospice Subsequent Visit,” dated  11/3/2025, the “Visit Note Report” indicated Patient 9 had a Stage IV pressure sore (severe open wound that affected all layers of the skin to expose deep tissues like muscle, tendon, or bone due to the prolonged pressure on the skin).During an interview and a concurrent review of Patient 9’s clinical records with the DPCS on 11/18/2025 at 12:38 p.m., Patient 9’s nursing assessments, previous health history, care plans, medication list, and visit notes were reviewed. The DPCS stated there was no documented evidence of any initial assessment and ongoing assessments of Patient 9’s BG monitoring and assessment of any antidiabetic medications. The DPCS stated this failure could lead to worsening or delayed healing of Patient 9’s pressure wound due to possible uncontrolled BG levels.During a review of the HA’s undated policy and procedures (P&P 1), titled “Initial Assessment,” P&P 1 indicated the following:1.      During the initial patient assessment, all baseline data and other relevant information must be documented in the patient’s clinical record, including no less than the following information, as relevant:a.      Patient’s past and present medical and psychosocial history, including pertinent diagnosesb.      Current and related past medications, including prescription and over-the-counter medicationsc.      Laboratory resultsd.      Medical, alcohol, and other drug historye.      Specific, individualized patient needs/problems pertinent to the hospice care being provided.f.        The patient’s and family/caregiver’s educational needs, abilities, motivation, and readiness to learn2.      Based upon the findings of the reassessment, additional orders must be generated and forwarded to the physician for signature.3.      The physician must be notified to verify any changes in medications, including over-the-counter medications, and treatment/interventions that require physician approval.

Based on observation, interview, and record review, the Hospice Agency (HA, an agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure a complete and accurate medication profile review (comprehensive assessment of the patient’s medications to identify and resolve any issues to ensure the medications are appropriate and safe for the patient) was conducted for one of 14 sampled patients (Patient 4) by failing to: Ensure the skilled nurse (SN) identified the medication discrepancies and verified with Patient 4’s physician the medication orders on amlodipine (medication to treat high blood pressure [BP, force of blood pushing against artery walls as the heart pumps]), acetaminophen (medication to treat mild to moderate pain), Dulcolax (medication to treat constipation), and Robitussin (medication to treat cold and cough symptoms) during the medication profile review performed at every home visit.Ensure Registered Nurse (RN 2) provided an updated list of Patient 4’s medications that included the new physician’s order for Miralax (medication to treat constipation) to Patient 4’s family/caregivers during the home visit on 11/14/2025.These deficient practices had the potential to lead to an ineffective drug therapy and adverse drug reactions (harmful, unintended, or unexpected reaction to a medication when taken at normal doses) that could impact the patient's health status and wellbeing. --- Findings:During a review of Patient 4’s medication profile sheet, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 4’s initial start of care (SOC) on 9/14/2025 with diagnoses that included Alzheimer’s disease (progressive brain disorder that causes memory loss and decline in mental ability) and chronic kidney disease (gradual loss of kidney function due to the kidney damage causing the inability to filter blood properly).During a review of Patient 4’s “Hospice Recert Summary Report,” dated 11/5/2025, the “Hospice Recert Summary Report” indicated the following:1.      Skilled Nurse (SN) Visit once a week and as needed effective 11/13/20252.      Current physician-ordered medications include:i.        1/17/2025 – acetaminophen 650 milligrams (mg, unit of measurement of weight) 1 suppository (bullet-shaped medication to be inserted into the rectum to be dissolved) rectally every 6 hours/4 hours (physician order was not clarified) if temperature is greater than 100 degrees Fahrenheitii.      1/17/2025 – Dulcolax 10 mg 1 suppository rectally if no bowel movement (BM) is present in 48 hours. Provide it daily until BM. Hold it after the BM for 48 hours.iii.    1/30/2025 - amlodipine 2.5 mg take 1 tablet daily as needed for systolic BP (SBP, top number in a BP reading that indicates pressure in the arteries when the heart contracts) greater than 160 millimeters of Mercury (mm Hg, unit of measurement of pressure with the normal SBP less than 120 mm Hg)iv.    3/22/2025 – Robitussin nighttime cough DM 3.125 mg-7.5 mg per 5 milliliter (ml, unit of measurement of volume) oral liquid 1 tablespoon (15 ml) every 6 hours as needed for coughv.      11/10/2025 – Miralax 17 grams mixed with 8 ounces of beverage given nightly. Hold if loose stool/diarrhea observedAn observation and concurrent interview, during a joint home visit at Patient 4’s living room, on 11/14/2025 at 11:30 AM, with Registered Nurse (RN) 2, Patient 4’s medication bottles, medication list at home, and active physician medication orders were reviewed. RN 2 stated the following:1.      The medication label for acetaminophen suppository was inconsistent with the physician’s order as the medication label indicated to administer 1 suppository per rectum every 6 hours as needed for temperature above 101 degrees Fahrenheit.2.      RN 2 stated the medication label for Dulcolax 10 mg suppository was inconsistent with the physician’s order as the medication label indicated to insert 1 suppository per rectum if no BM in 72 hours.3.      RN 2 stated he ordered amlodipine two weeks ago, but there was no documented evidence that it was ordered and delivered to Patient 4’s home. RN 2 stated Patient 4 had not been administered amlodipine recently, because Patient 4’s BP had not been very high for months.4.      RN 2 stated Robitussin nighttime cough DM (cough medication with dextromethorphan [cough suppressant] 30 mg per 20 ml dose and doxylamine succinate [antihistamine, antiallergy] 12.5 mg per 20 ml dose as active ingredients) was not available in Patient 4’s home as ordered by the physician, but Geri-Tussin DM (cough medication with active ingredients dextromethorphan 10 mg and Guaifenesin 100 mg [expectorant]) was filled by the pharmacy on 10/24/2025 and delivered to Patient 4’s home. RN 2 stated the medication available in Patient 4’s home was different from what was prescribed/ordered by the physician and needed to be clarified with the physician and pharmacy.5.      RN 2 stated Patient 4’s physician order for Miralax 17 grams was not yet reflected on Patient 4’s copy of the medication list at home because it was recently ordered on 11/7/2025. RN 2 did not have an updated copy of the medication list to provide to Patient 4’s caregiver/s.During an interview and a concurrent review of Patient 4’s clinical records with the Director of Patient Care Services (DPCS) on 11/17/2025 at 2:12 p.m., Patient 4’s nursing assessments, previous health history, care plans, medication list, and visit notes were reviewed. The DPCS stated the SNs must conduct a medication profile review during every home visit and provide an updated list of medications to the patient (in general) and/or caregiver/s. The DPCS stated the VNs must compare the physician’s medication orders against the updated medication list and the medication bottles to ensure that there are no discrepancies. The DPCS stated when the discrepancies were found during a SN home visit, the VNs should have notified and clarified with the physician the medication orders on acetaminophen, Dulcolax, and Robitussin. The DPCS stated although the amlodipine was ordered on an as needed basis, amlodipine must always be readily available in Patient 4’s home and ready for use by Patient 4. During a review of the HA’s undated policy and procedures (P&P), titled “Medication Profile,” the P&P indicated the following:1.      Patients receiving medications administered by the HA must have a current, accurate medication profile in the clinical record.2.      Medication profiles must be updated for each change to reflect current medications and new and/or discontinued medications.3.      A drug regimen review must be performed at the time of admission and on an ongoing basis to assist in evaluating effectiveness and appropriateness; identify potential and actual drug/food interactions; adverse reactions, and duplicate therapy and noncompliance issues.4.      During subsequent hospice visits, the medication profile must be used as a care planning and teaching guide to assure that the patient and family/caregiver, as well as other case managers, understand the medication regimen.5.      Deviations in taking medications as ordered must be documented in the clinical notes, and the physician must be notified.6.      The case manager must review the medication label for name, additional patient identifier, drug dosage, and prescription.

Based on interview and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure the HA licensed nurses conducted and documented the complete and accurate ongoing assessment for one of 14 sampled patients (Patient 6) to reflect the patient’s current condition and antidiabetic medications and to ensure the correct treatments and services were provided.This failure had the potential to result in an ineffective drug therapy and inappropriate care and services not meeting Patient 6’s individualized medical needs. --- Findings:During a review of Patient 6’s profile sheet, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 6’s start of care (SOC) on 8/8/2025 with diagnoses that included liver cell cancer, malignant ascites (accumulation of fluid in the abdomen caused by cancer cells in the lining of the abdominal cavity) benign prostatic hyperplasia (non-cancerous enlargement of the prostate gland), and type 2 diabetes mellitus (DM II, long-term condition in which the body is unable to maintain normal blood glucose [BG, blood sugar] levels).During a review of Patient 6’s “Visit Note Report (VNR 1),” dated 10/15/2025, “VNR 1” indicated Registered Nurse (RN) 1 documented that there were “no problems identified” under “abnormal endocrine (any gland that secretes hormones directly into the bloodstream like pancreas that produces the hormone insulin to regulate BG levels) findings.” However, RN 1 documented under the narrative that fasting BG (test that measures BG after an overnight fast of at least 8 hours with the normal fasting BG level between 70 milligrams per deciliter [mg/dL, measurement of mass of a substance in a given fluid volume] and 100 mg/dL) increased from around 90 mg/dL with a peak of 80mg/dL - 100mg/dL. RN 1 documented “the average [BG] also increased,” so RN 1 recommended to provide the Metformin (antidiabetic medication) dose at night.During a review of Patient 6’s “Visit Note Report (VNR 2),” dated 10/20/2025, “VNR 2” indicated RN 1 documented that there were “no problems identified” under “abnormal endocrine findings.” However, RN 1 documented under the narrative that the fasting BG level was 78 mg/dL to 90 mg/dL in the last 7 days, and at 5 p.m., it was between 155mg/dL – 200mg/dL (non-fasting BG level of 200 mg/dL or above typically indicates high BG). RN 1 documented that Patient 6 was not taking the Metformin at night.During a review of Patient 6’s “Visit Note Report (VNR 3),” dated 10/27/2025, “VNR 3” indicated RN 1 documented that there were “no problems identified” under “abnormal endocrine findings.” However, RN 1 documented under the narrative that fasting BG level was between 73 mg/dL to 90 mg/dL in the last 7 days, and at 5 p.m., it was between 175 mg/dL – 230 mg/dL. RN 1 documented that Patient 6 is not taking the Metformin at night.During a review of Patient 6’s “Visit Note Report (VNR 4),” dated 11/3/2025, “VNR 4” indicated RN 1 documented that there were “no problems identified” under “abnormal endocrine findings.” However, RN 1 documented under the narrative that “due to the lack of Januvia (antidiabetic medication) and the wife continued providing one Metformin daily only, the glucose (Patient 6’s BG) had some elevated numbers but not different than usual.”During a review of Patient 6’s “Hospice Recert Summary Report,” dated 11/5/2025, the “Hospice Recert Summary Report” indicated the following physician medication orders:1.      6/20/2024 – Januvia 50 milligrams (mg) 1 tablet orally daily for glucose control2.      9/8/2024 – Metformin 500 mg 1 tablet orally twice a day for glucose control3.      10/9/2025 – Discontinue Lantus (antidiabetic medication)15 units. Add Lantus 10 units subcutaneously (under the skin) daily at 5 p.m. for high BG. Hold if Glucose Reading value is lower or equal to 150 mg/dL.During an interview and a concurrent review of Patient 6’s clinical records on 11/17/2025 at 2:12 p.m. with the Director of Patient Care Services (DPCS), Patient 6’s ongoing assessments, previous health history, care plans, physician orders, medication list, and visit notes were reviewed. The DPCS stated the endocrine assessments of the home visits were inconsistent with the narratives regarding blood sugar problems, noncompliance with the diabetic treatment plan, and changes in the antidiabetic medication orders. The DPCS stated complete and accurate assessments must be documented on the patient’s (in general) visit notes to ensure proper treatment and services are provided to the patient.During a review of the HA’s undated P&P, titled “Ongoing Assessments,” the P&P indicated the following:1.      The scope and intensity of ongoing hospice patient assessments must be determined by the patient’s prognosis, diagnoses, condition, desire for care, response to previous care, and the care setting.2.      During each home visit, the case manager and/or other disciplines must re-evaluate the patient according to the problems identified during the initial visit and subsequent visits.3.      The case manager must assess the patient on each visit for:a.      Secondary symptoms related to the terminal illness such as nausea, vomiting, respiratory distress and the patient’s response to medications and other interventionsb.      Factors that alleviate or exacerbate physical symptomsc.      Current treatment related to the identified symptoms and the patient’s responsed.      Vital signs appropriate to the patient’s condition4.      Based on the reassessments, the plan of care—including problems, needs, goals, and outcomes—must be reviewed and revised by the hospice case manager in collaboration with all hospice IDG members responsible for the case.

Based on observation, interview and record review, the hospice agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure the Condition of Participation (CoP, a set of minimum professional standards all hospice agencies must meet to participate in Medicare [federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) for Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) Care Planning, and Coordination of Services was met as follows: --- 1. The Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure the physician and spiritual counselor had documented attendance during the interdisciplinary group (IDG, team composed of the Registered Nurse [RN], Medical Social Worker [MSW], spiritual counselor [SC], and physician [MD] who discuss the patients’ plan of care to provide the best individualized care and support to patients and families) meetings at least every two weeks to discuss the physical, psychosocial, emotional, and spiritual needs of five of 14 sampled patients (Patient 4, Patient 5, Patient 6, Patient 8, and Patient 9). This failure had the potential to result in patients not being provided with the care and services necessary in their end-of-life process (Refer to L539).2. The HA failed to ensure that the care plans (CP) for five of 14 sampled patients (Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9) were individualized based on the patients’ current health status and personal needs.     a.      For Patient 5, the HA failed to ensure an individualized CP to include blood glucose (BG, blood sugar) monitoring and monitoring of Patient 5 being in “transitioning” phase was developed and implemented.b.      For Patient 6, the HA failed to ensure an individualized CP to include BG monitoring was developed and implemented.c.      For Patient 7, the HA failed to ensure an individualized CP to reflect the diagnosis of diabetes mellitus type 2 (DM II, long-term condition in which the body is unable to maintain normal BG levels) was developed and implemented.d.      For Patient 8, the HA failed to ensure an individualized CP was developed, implemented for the episode of very high blood pressure (BP, force of blood against the arteries with the normal BP as 120/80 millimeters of Mercury [mm Hg, unit of pressure measurement]) of 158/106 mm Hg on 8/26/2025 and that included the parameters for the Valsartan (medication to treat high BP) ordered by the physician.e.      For Patient 9, the HA failed to ensure an individualized CP to reflect the diagnosis of DM II and wound to the coccyx (tailbone) was developed and implemented.These failures had the potential to result in patients not being provided with the care and services required and needed in their end-of-life process (Refer to L545).3.    The HA failed to ensure that the plans of care (POC) for six of 14 sampled patients (Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9) were individualized to reflect the patients’ current pain level and pain management plan by failing to:a.      Ensure the HA nurse developed an individualized POC for Patient 4’s concurrent physician orders for morphine (powerful opioid medication to treat severe pain) and lorazepam (medication to treat anxiety [excessive worry and fear that interfere with daily life] by slowing down the central nervous system [CNS]).b.      Ensure the HA nurse developed an individualized POC for Patient 5’s concurrent physician orders for Fentanyl (powerful synthetic opioid medication 50 to 100 times more potent than Morphine to treat severe pain), lorazepam, and morphine.c.      Ensure the HA nurse developed an individualized CP for Patient 6’s concurrent physician orders for lorazepam, Norco (combination of acetaminophen [medication to treat mild to moderate pain] and opioid medication hydrocodone), and morphine.d.      Ensure the HA nurse developed an individualized POC for Patient 7’s concurrent physician orders for lorazepam, morphine, and Zolpidem (prescription sleeping pill that slows down the CNS).e.      Ensure the HA nurse developed an individualized POC for Patient 8’s concurrent physician orders for Norco, alprazolam (medication to treat anxiety by slowing down the CNS), lorazepam, Morphine, and Carbidopa-Levodopa (medication to treat Parkinson’s disease [progressive neurological disorder affecting movement]).f.        Ensure the HA nurse developed an individualized POC for Patient 9’s concurrent physician orders for hydrocodone/ibuprofen (combination of opioid and a non-steroidal anti-inflammatory drug to treat pain), lorazepam, and Morphine.These failures had the potential to result in ineffective pain management and/or increased sedation due to the possible concurrent use of multiple high-risk medications related to not assessing and documenting pain management needs and the effectiveness of all high-risk medications during their end-of-life (Refer to L549).The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure provision of quality care and services to patients certified to receive the hospice benefits.

Based on interview and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure the physician and spiritual counselor documented their attendance during the interdisciplinary group (IDG, team composed of the Registered Nurse [RN], Medical Social Worker [MSW], spiritual counselor [SC], and physician [MD] who discuss the patients’ plan of care to provide the best individualized care and support to patients and families) meetings at least every two weeks to discuss the physical, psychosocial, emotional, and spiritual needs of five of 14 sampled patients (Patient 4, Patient 5, Patient 6, Patient 8, and Patient 9). This failure had the potential to result in patients not being provided with the care and services necessary during the course of the terminal illness. --- Findings:a.      During a review of Patient 4’s profile sheet, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 4’s initial start of care (SOC) on 9/14/2025 with diagnoses that included Alzheimer’s disease (progressive brain disorder that causes memory loss and decline in mental ability) and chronic kidney disease (gradual loss of kidney function due to the kidney damage causing the inability to filter blood properly).During a review of Patient 4’s “Hospice Recert Summary Report,” dated 11/5/2025, the “Hospice Recert Summary Report” indicated the following:-For IDG meeting note, dated 11/5/2025, MD did not sign the IDG note.-For IDG meeting notes, dated 10/17/2025, 10/3/2025, and 9/19/2026 - MD signed the IDG note on 10/31/2025.b.     During a review of Patient 5’s profile sheet, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 5’s start of care (SOC) on 10/31/2025 with diagnoses that included liver cirrhosis (late stage of liver disease), hepatic encephalopathy (brain disorder caused by advanced liver disease that prevents liver from filtering toxins, like ammonia, from the blood), and diabetes mellitus long-term condition in which the body is unable to maintain normal blood glucose [BG, blood sugar] levels.During a review of Patient 5’s “Hospice Recert Summary Report,” dated 11/5/2025, the “Hospice Recert Summary Report” indicated for the IDG meeting, dated 11/5/2025, the MD did not sign the IDG note (Electronic Signature Date left blank).c.      During a review of Patient 6’s profile sheet, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 6’s start of care (SOC) on 8/8/2025 with diagnoses that included liver cell cancer, malignant ascites (accumulation of fluid in the abdomen caused by cancer cells in the lining of the abdominal cavity) benign prostatic hyperplasia (non-cancerous enlargement of the prostate gland), and type 2 diabetes mellitus (DM II).During a review of Patient 6’s “Hospice Recert Summary Report,” dated 11/5/2025, the “Hospice Recert Summary Report” indicated the following:-For IDG meeting note, dated 11/5/2025 – MD did not sign the IDG note.-For IDG meeting notes, dated 10/22/2025, 10/8/2025, 9/24/2025, 9/10/2025, 8/27/2025, and 8/13/2025 – MD signed the IDG note on 10/31/2025.d.      During a review of Patient 8’s profile sheet, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 8’s start of care (SOC) on 8/26/2025 with diagnoses that included Parkinsonism (syndrome characterized by symptoms such as tremors, rigidity, and slowness of movement), anorexia (eating disorder characterized by a distorted body image, extreme weight loss, and intense fear of gaining weight), physical debility (state of general weakness), depression (serious mood disorder characterized by persistent sadness and/or loss of interest in activities that interfere with daily life), and anxiety disorder (excessive worry about real or perceived threats).During a review of Patient 8’s “Hospice Recert Summary Report,” dated 11/15/2025, the “Hospice Recert Summary Report” indicated the following:-For IDG meeting note, dated 11/5/2025 – MD did not sign the IDG note.-For IDG meeting notes, dated 10/22/2025, 10/8/2025, 9/24/2025, 9/10/2025, and 8/27/2025 – MD signed the IDG note on 10/31/2025.e.      During a review of Patient 9’s profile sheet, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 9’s SOC on 7/13/2025 with diagnoses that included Alzheimer’s disease, DM II with diabetic cataract (complication of DM II characterized by the clouding of the eye’s lens due to high BG levels) and diabetic polyneuropathy (complication of DM II characterized by nerve damage, oftentimes affecting the legs and feet, due to high BG levels).During a review of Patient 9’s “Hospice Recert Summary Report,” dated 11/5/2025, the “Hospice Recert Summary Report” indicated for the IDG meeting, dated 11/5/2025, the MD did not sign the IDG note.During a review of Patient 9’s “Hospice Recert Summary Report,” dated 10/21/2025, the “Hospice Recert Summary Report” indicated the following:-For IDG meeting notes, dated 8/27/2025, 9/10/2025, 9/24/2025, 10/8/2025, and 10/21/2025 – MD signed the IDG notes on 10/31/2025.-For IDG meeting notes, dated 7/30/2025 and 8/13/2025, the MD did not sign the IDG note.-For IDG meeting notes, dated 7/2025 and 7/16/2025 – MD signed the IDG notes on 9/29/2025.During an interview and a concurrent review on 11/17/2025 at 2:37 p.m. with the Director of Patient Care Services (DPCS), IDG meeting sign-in sheets were reviewed. The DPCS stated the MD attended the IDG meetings via telephone and the SC attended the IDG meetings in-person every other Wednesday. The DPCS stated she signed “via phone” on the space provided for the Medical Director signature on 11/15/2025, 10/22/2025, and 10/8/2025. However, the DPCS stated there was no documented evidence that the Medical Director attended the IDG meetings, dated 9/24/2025, 9/10/2025, 8/13/2025, 7/30/2025, 7/16/2025, and 7/2/2025. In addition, the DPCS stated there was no documented evidence that the SC attended the IDG meetings, dated 10/22/2025 and 9/24/2025. The DPCS stated it was important for the MD, RN, SC, and MSW to attend the IDG meetings at least every two weeks to ensure all members of the team are all “on the same page” by being updated about what is happening to the patients, agreeing on the plan of care to be provided, and  being aware of the new physician’s orders to be carried out.During a review of the HA’s undated P&P 1, titled “Interdisciplinary Team Coordination of Care,” P&P 1 indicated the following:1.      The interdisciplinary group must maintain responsibility for the provision and coordination of care, regardless of the setting where care is provided to its patients.2.      Written evidence of care coordination must be found in the plan of care and/or interdisciplinary team meeting forms in the patient’s clinical record and must involve the patient’s attending physician.3.      The IDG must conduct assessments, develop and update the plan of care, and review the effectiveness of care a minimum of every two weeks. The attending physician must receive a copy of the care plan updates.4.      All IDG members, including those providing contracted services, must have access to the plan of care to ensure coordination and continuity of care.During a review of the HA’s undated P&P 2, titled “Entries into the Clinical Record,” P&P 2 indicated the following:1.      Documentation in the clinical record must be timely, detailed, accurate, and reflect the care or services provided.2.      A clinical record must be initiated and maintained for each patient receiving care or services according to organization policies and must include at a minimum:a.      Pertinent medical historyb.      Physician orders and evidence of physician oversight activitiesc.      Changes to the plan of cared.      Dates, times, and types of interventions, assessments, and coordination of caree.      Patient response to care and services analyzed and documented as measurable goalsf.        Current patient status and progress towards goalsg.      Patient and family education3.      Entries into the clinical record must be clear, concise, and specific statements of fact.4.      All entries into the clinical record must reflect the date care was provided, month, day, and year, and must be submitted to the office within 1 business day of the date of the services.

Based on interviews and record review, the hospice agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure written the plans of care (POC) for five of 14 sampled patients (Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9) were individualized identifying the patients’ current health status and personal needs.     a.      For Patient 5, the HA failed to ensure an individualized POC identifying blood glucose (BG, blood sugar) monitoring and Patient 5"s “transitioning” phase (final phase of life when a person is nearing death) was developed and implemented.b.      For Patient 6, the HA failed to ensure an individualized POC to include BG monitoring was developed and implemented.c.      For Patient 7, the HA failed to ensure an individualized POC to reflect the diagnosis of diabetes mellitus type 2 (DM II, long-term condition in which the body is unable to maintain normal BG levels) was developed and implemented.d.      For Patient 8, the HA failed to ensure an individualized POC was developed, implemented for the episode of very high blood pressure (BP, force of blood against the arteries with the normal BP as 120/80 millimeters of Mercury [mm Hg, unit of pressure measurement]) of 158/106 mm Hg on 8/26/2025 and that included the parameters for the Valsartan (medication to treat high BP) ordered by the physician.e.      For Patient 9, the HA failed to ensure an individualized POC to reflect the diagnosis of DM II and wound to the coccyx (tailbone) was developed and implemented.These failures had the potential to result in patients not being provided with the care and services required and needed in their end-of-life process. --- Findings:a.      During a review of Patient 5’s profile sheet, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 5’s start of care (SOC) on 10/31/2025 with diagnoses that included liver cirrhosis (late stage of liver disease), hepatic encephalopathy (brain disorder caused by advanced liver disease that prevents liver from filtering toxins, like ammonia, from the blood), and diabetes mellitus (long-term condition in which the body is unable to maintain normal blood glucose [BG, blood sugar] levels).During an interview and a concurrent record review on 11/17/2025 at 2:37 p.m. with the Director of Patient Care Services (DPCS), Patient 5’s profile sheet, visit notes, physician orders, and care plans were reviewed. The DPCS stated Patient 5’s POC was not individualized to reflect Patient 5’s current condition, who was “transitioning (final phase of life when a person is nearing death)” and was having BG issues. The DPCS stated Patient 5’s plan of care must be individualized to ensure all staff are aware of the treatment and services to be provided and ensure continuity of care.b.      During a review of Patient 6’s profile sheet, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 6’s start of care (SOC) on 8/8/2025 with diagnoses that included liver cell cancer, malignant ascites (accumulation of fluid in the abdomen caused by cancer cells in the lining of the abdominal cavity) benign prostatic hyperplasia (non-cancerous enlargement of the prostate gland), and type 2 diabetes mellitus (DM II).During an interview and a concurrent record review on 11/17/2025 at 2:37 p.m. with the DPCS, Patient 6’s profile sheet, visit notes, physician orders, and care plans were reviewed. The DPCS stated Patient 6’s POC was not individualized to reflect the BG problem. The DPCS stated Patient 6’s POC must be based on complete and accurate assessments, including of BG levels, to ensure all staff are “aware of what’s going on” and could provide the necessary care and services required to maintain Patient 6’s comfort and well-being.c.      During a review of Patient 7’s profile sheet, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 7’s start of care (SOC) on 11/6/2025 with diagnoses that included Alzheimer’s disease (progressive brain disorder that causes memory loss and decline in mental ability) and DM II with diabetic chronic kidney disease (diabetic complication characterized by the damage to the kidneys’ filtering system due to uncontrolled BG levels).During an interview and a concurrent record review on 11/17/2025 at 2:37 p.m. with the DPCS, Patient 7’s profile sheet, visit notes, physician orders, and care plans were reviewed. The DPCS stated Patient 7’s POC was not individualized to reflect the DM II diagnosis. The DPCS stated given the presence of a diabetic complication, Patient 7’s baseline BG levels must be assessed by the HA nurse to ensure the BG levels “do not get out of control” and affect Patient 7’s well-being. The DPCS stated hypoglycemia could lead to confusion, coma (state of deep unconsciousness), hospitalization, and death.d.      During a review of Patient 8’s profile sheet, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 8’s start of care (SOC) on 8/26/2025 with diagnoses that included Parkinsonism (syndrome characterized by symptoms such as tremors, rigidity, and slowness of movement), anorexia (eating disorder characterized by a distorted body image, extreme weight loss, and intense fear of gaining weight), physical debility (state of general weakness), depression (serious mood disorder characterized by persistent sadness and/or loss of interest in activities that interfere with daily life), and anxiety disorder (excessive worry and fear that interferes with daily life).During an interview and a concurrent record review on 11/17/2025 at 2:37 p.m. with the DPCS, Patient 8’s profile sheet, visit notes, physician orders, and POC were reviewed. The DPCS stated Patient 8’s POC was not individualized to reflect an episode of a very high blood pressure of 158/106 mm Hg on 8/26/2025 that required the Valsartan medication order. The DPCS stated there must be an individualized care plan for high BP to include Valsartan as an intervention with the proper parameters ordered to indicate when to administer or hold the medication and call the physician. The DPCS stated it is “essential to keep the hypertension under control” to ensure Patient 8 does not experience complications, such as, stroke.e.      During a review of Patient 9’s profile sheet, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 9’s SOC on 7/13/2025 with diagnoses that included Alzheimer’s disease, DM II with diabetic cataract (complication of DM II characterized by the clouding of the eye’s lens due to high BG levels) and diabetic polyneuropathy (complication of DM II characterized by nerve damage, oftentimes affecting the legs and feet, due to high BG levels).During an interview and a concurrent record review on 11/18/2025 at 12:38 p.m. with the DPCS, Patient 9’s profile sheet, visit notes, physician orders, and POC were reviewed. The DPCS stated Patient 9’s POC was not individualized to reflect Patient 9’s wound and DM II diagnosis. The DPCS stated it was important to know Patient 9’s baseline BG levels because keeping the BG levels under control prevents further delay in the healing of Patient 9’s wound.During a review of the HA’s undated policy and procedures (P&P 1), titled “The Initial Plan of  Care,” “P&P 1” indicated the following:1.      The initial plan of care must be developed by the admitting nurse at the time of the initial visit and must be consistent with the patient’s and family/caregiver’s immediate care needs.2.      The following areas must be reviewed with the patient/family:a.      Problems identified and interventions including family/caregiver care education needsb.      Goals establishedc.      Level of Care, treatment, and service planned with frequency of visitsd.      Medication administration and side effectsDuring a review of the HA’s undated “P&P 2,” titled “Interdisciplinary Team (IDT, consists, at a minimum, of the physician, registered nurse, social worker, and a counselor) Plan of Care,” “P&P 2” indicated the following:1.      The purpose of the IDT plan of care was to provide direction to the IDG providing care to the patient and family/caregiver.2.      A comprehensive patient and family/caregiver interdisciplinary plan of care must be established and maintained for each individual admitted to the hospice program.3.      Care decisions and services to be provided must be made as a result of the care planning process, analysis of initial and ongoing assessments, and analysis of patient response to care against goals and outcomes.4.      The care provided to the patient must be in accordance with the plan of care and must be reviewed on a regular basis and revised as frequently as deemed necessary, but no less than biweekly, by the IDG based on ongoing assessments of the patient and family/caregiver. The review must be documented on the clinical record with the revision dates noted on the plan of care.5.      The plan of care must be based on identified problems, goals, and interventions.6.      Any change in patient’s condition may result in a change in the plan of care.7.      The patient and family/caregiver and attending physician must participate in the development of and continued updating of the plan of care and ongoing changes. A comprehensive review of the plan of care must be done at the time of significant changes, at the end of hospice certification period, and or at least every ninety days, whichever is sooner.8.      The plan of care must include an assessment of the individual’s needs and identification of the services, including the management of pain and discomfort and symptom relief.9.      All problems/needs must be prioritized, with corresponding goals and anticipated dates for reaching those goals.10. Each patient must be monitored for his/her response to care or services provided against established patient goals and patient outcomes to determine if goals have been achieved.11. As needed, patients/families must receive written instructions regarding treatments or aspects of care that will be responsibility of the patient and family/caregiver to manage.12. The comprehensive plan of care must contain, but will not be limited to, the following:a.      Diagnosesb.      Assessment/identification of patient and family/caregiver needs, including physical, functional, nutritional, psychosocial, cognitive, cultural, spiritual, counseling, and educational.c.      Statement of treatment goalsd.      Individualized interventionse.      Pain and symptom managementf.        Medications and treatments, including allergiesg.      Physician orders

Based on interviews and record review, the hospice agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure the plan of care (POC) for six of 14 sampled patients (Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9) were individualized to reflect the patients’ current pain level and pain management plan by failing to:a.      Ensure the HA nurse developed an individualized POC for Patient 4’s concurrent physician orders for morphine (powerful opioid medication to treat severe pain) and lorazepam (medication to treat anxiety [excessive worry and fear that interfere with daily life] by slowing down the central nervous system [CNS]).b.      Ensure the HA nurse developed an individualized POC for Patient 5’s concurrent physician orders for Fentanyl (powerful synthetic opioid medication 50 to 100 times more potent than Morphine to treat severe pain), lorazepam, and morphine.c.      Ensure the HA nurse developed an individualized POC for Patient 6’s concurrent physician orders for lorazepam, Norco (combination of acetaminophen [medication to treat mild to moderate pain] and opioid medication hydrocodone), and morphine.d.      Ensure the HA nurse developed an individualized POC for Patient 7’s concurrent physician orders for lorazepam, morphine, and Zolpidem (prescription sleeping pill that slows down the CNS).e.      Ensure the HA nurse developed an individualized POC for Patient 8’s concurrent physician orders for Norco, alprazolam (medication to treat anxiety by slowing down the CNS), lorazepam, Morphine, and Carbidopa-Levodopa (medication to treat Parkinson’s disease [progressive neurological disorder affecting movement]).f.        Ensure the HA nurse developed an individualized POC for Patient 9’s concurrent physician orders for hydrocodone/ibuprofen (combination of opioid and a non-steroidal anti-inflammatory drug to treat pain), lorazepam, and Morphine.These failures had the potential to result in ineffective pain management and/or increased sedation due to the possible concurrent use of multiple high-risk medications related to not assessing and documenting pain management needs and the effectiveness of all high-risk medications during their end-of-life. --- Findings:a.      During a review of Patient 4’s profile sheet, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 4’s initial start of care (SOC) on 9/14/2025 with diagnoses that included Alzheimer’s disease (progressive brain disorder that causes memory loss and decline in mental ability) and chronic kidney disease (gradual loss of kidney function due to the kidney damage causing the inability to filter blood properly).During a review of Patient 4’s “Medicine List” as of 11/12/2025, the “Medicine List” indicated the following physician orders:1.      Lorazepam 2 milligrams per milliliter (mg/ml) orally or under the tongue every 2 hours as needed for restlessness or agitation. Give 0.25 mL for mild anxiety and 0.5 mL for medium-high anxiety level.2.      Morphine 100 mg/5 mL orally or under the tongue every 2 hours as needed for pain. Give 0.25 mL (5 mg) for pain scale 4-6 (out of 10), 0.50 mL (10 mg) for pain scale 7-8 (out of 10), 0.75 ml (15 mg) for pain scale 9-10 (out of 10), and 1 ml (20 mg) for pain scale 10/10.b.      During a review of Patient 5’s profile sheet, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 5’s SOC on 10/31/2025 with diagnoses that included liver cirrhosis (late stage of liver disease), hepatic encephalopathy (brain disorder caused by advanced liver disease that prevents liver from filtering toxins, like ammonia, from the blood), and diabetes mellitus (long-term condition in which the body is unable to maintain normal blood glucose [BG, blood sugar] levels).During a review of Patient 5’s “Medicine List” as of 11/13/2025, the “Medicine List” indicated the following physician orders:1.      Fentanyl 40 mg tablet 1 patch transdermal every 72 hours for pain2.      Lorazepam 0.5 mg orally every 6 hours for anxiety3.      Lorazepam 0.5 mg orally every 4 hours as needed for anxiety/agitation4.      Morphine 100 mg/5 ml orally or under the tongue 5 mg every 2 hours as needed for pain. Give 5 mg every 2 hours as needed for mild pain 1-3 (out of 10), 10 mg every 2 hours as needed for moderate pain 4-6 (out of 10), and 15 mg every 2 hours as needed for severe pain 7-10 (out of 10).c.      During a review of Patient 6’s profile sheet, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 6’s SOC on 8/8/2025 with diagnoses that included liver cell cancer, malignant ascites (accumulation of fluid in the abdomen caused by cancer cells in the lining of the abdominal cavity) benign prostatic hyperplasia (non-cancerous enlargement of the prostate gland), and type 2 diabetes mellitus (DM II).During a review of Patient 6’s “Medicine List” as of 11/13/2025, the “Medicine List” indicated the following physician orders:1.      Hydrocodone 5 mg-acetaminophen 325 mg 1 tablet orally every 6 hours as needed for pain2.      Morphine 100 mg/5 ml 0.25 – 1 ml orally or under the tongue every 2 hours as needed for pain/shortness of breath. Give 0.25 ml for pain 1-3 (out of 10), 0.50 ml for pain 4-6 (out of 10), 0.75 ml for pain 7-8 (out of 10), and 1 ml for pain 9-10 (out of 10).3.      Lorazepam 2 mg/ml 0.25-1 ml orally or under the tongue every 2 hours as needed for anxiety/agitation. Give 0.25 ml for anxiety/agitation/shortness of breath. Give 0.5 ml for mild anxiety/agitation/shortness of breath. Give 0.75 ml for moderate anxiety/agitation/shortness of breath. Give 1 ml for severe anxiety/agitation/shortness of breath.d. During a review of Patient 7’s profile sheet, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 7’s SOC on 11/6/2025 with diagnoses that included Alzheimer’s disease and DM II with diabetic chronic kidney disease (diabetic complication characterized by the damage to the kidneys’ filtering system due to uncontrolled BG levels).During a review of Patient 7’s “Medicine List” as of 11/13/2025, the “Medicine List” indicated the following physician orders:1.      Lorazepam 2 mg/ml orally or under the tongue every 2 hours as needed for restlessness or agitation. Give 0.25 mL for mild anxiety and 0.5 mL for medium-high anxiety level.2.      Morphine 20 mg/1 mL orally or sublingual every 2 hours as needed for pain. Give 0.25 mL (5 mg) for pain scale 4-6 (out of 10), 0.50 mL (10 mg) for pain scale 7-8 (out of 10), 0.75 ml (15 mg) for pain scale 9-10 (out of 10), and 1 ml (20 mg) for pain scale 10/10 and call HA.3.      Zolpidem 5 mg 1 tablet at bedtime to improve sleeping. Repeat in 2 hours if the first tablet is not effective.e.      During a review of Patient 8’s profile sheet, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 8’s SOC on 8/26/2025 with diagnoses that included Parkinsonism (syndrome characterized by symptoms such as tremors, rigidity, and slowness of movement), anorexia (eating disorder characterized by a distorted body image, extreme weight loss, and intense fear of gaining weight), physical debility (state of general weakness), depression (serious mood disorder characterized by persistent sadness and/or loss of interest in activities that interfere with daily life), and anxiety disorder (excessive worry and fear that interfere with daily life).During a review of Patient 8’s “Medicine List” as of 11/13/2025, the “Medicine List” indicated the following physician orders:1.      Alprazolam 1 mg tablet orally three times a day as needed for anxiety2.      Lorazepam 2 mg/ml 0.25 ml-0.5 ml every 2 hours as needed for anxiety. Give 0.25 ml sublingually every 2 hours as needed for anxiety 3-5/10 and 0.5 ml sublingually every 2 hours as needed for anxiety of 6-10/10.3.      Hydrocodone 5 mg-acetaminophen 325 mg 1 tablet orally four times a daily as needed for pain.4.      Morphine 100 mg/5 ml 0.25 ml-1 ml every 2 hours as needed for pain. Give 0.25 ml sublingually every 2 hours as needed  for pain level 4-6 (out of 10), 0.5 ml sublingually every 2 hours as needed for pain level 7-8 (out of 10), 0.75 ml sublingually every 2 hours as needed for pain level 9-10 (out of 10). Give 1 ml sublingually every 2 hours as needed for pain level 10/10.5.      Carbidopa 10 mg-Levodopa 100 mg 1 tablet orally three times a day for Parkinson’s disease.f.      During a review of Patient 9’s profile sheet, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 9’s SOC on 7/13/2025 with diagnoses that included Alzheimer’s disease, DM II with diabetic cataract (complication of DM II characterized by the clouding of the eye’s lens due to high BG levels) and diabetic polyneuropathy (complication of DM II characterized by nerve damage, oftentimes affecting the legs and feet, due to high BG levels).During a review of Patient 9’s “Medicine List” as of 11/13/2025, the “Medicine List” indicated the following physician orders:1.      Hydrocodone 7.5 mg – ibuprofen 200 mg 0.5 tablet orally every 12 hours as needed for pain.2.      Children’s ibuprofen 100 mg/5 ml 10 ml orally every 6 hours as needed for pain or temperature above 100.5 degrees Fahrenheit3.      Lorazepam 1 mg/0.5 ml 0.5 mg orally or under the tongue every 2 hours as needed for anxiety or agitation4.      Morphine 100 mg/5 ml 5 mg orally or under the tongue every 2 hours as needed for pain. Give 5 mg every 2 hours as needed for mild pain, 10 mg every 2 hours as needed for moderate pain, and 15 mg every 2 hours as needed for severe pain.During an interview and a concurrent record review on 11/17/2025 at 2:37 p.m. with the Director of Patient Care Services (DPCS), the profile sheet, visit notes, physician orders, and care plans of Patients 4, 5, 6, 7, 8, and 9 were reviewed. The DPCS stated the patients’ care plans were not individualized to reflect the patients’ concurrent physician orders for multiple high-risk medications. The DPCS stated the patients’ care plans must be individualized to include the exact physician’s order for each high-risk medication and ensure its completeness and accuracy. The DPCS stated the patients’ care plans must be individualized to ensure the involvement of the patient and/or caregiver/s, ensure that all staff are aware of the risks and benefits of all the high-risk medications and goals of the treatment, and ensure all HA nurse will monitor the effectiveness of each high-risk medication. The DPCS stated it was important to ensure the care plans for the high-risk medications were individualized to prevent increased risks for adverse effects, such as excessive sedation or drowsiness that can lead to coma or death related to concurrent administration of the high-risk medications.During a review of the HA’s undated policy and procedures (P&P 1), titled “The Initial Plan of  Care,” “P&P 1” indicated the following:1.      The initial plan of care must be developed by the admitting nurse at the time of the initial visit and must be consistent with the patient’s and family/caregiver’s immediate care needs.2.      The following areas must be reviewed with the patient/family:5.      Problems identified and interventions including family/caregiver care education needs6.      Goals established7.      Level of Care, treatment, and service planned with frequency of visits8.      Medication administration and side effectsDuring a review of the HA’s undated “P&P 2,” titled “Interdisciplinary Team (IDT, consists, at a minimum, of the physician, registered nurse, social worker, and a counselor) Plan of Care,” “P&P 2” indicated the following:1.      The purpose of the IDT plan of care was to provide direction to the IDG providing care to the patient and family/caregiver.2.      A comprehensive patient and family/caregiver interdisciplinary plan of care must be established and maintained for each individual admitted to the hospice program.3.      Care decisions and services to be provided must be made as a result of the care planning process, analysis of initial and ongoing assessments, and analysis of patient response to care against goals and outcomes.4.      The care provided to the patient must be in accordance with the plan of care and must be reviewed on a regular basis and revised as frequently as deemed necessary, but no less than biweekly, by the IDG based on ongoing assessments of the patient and family/caregiver. The review must be documented on the clinical record with the revision dates noted on the plan of care.5.      The plan of care must be based on identified problems, goals, and interventions.6.      Any change in patient’s condition may result in a change in the plan of care.7.      The patient and family/caregiver and attending physician must participate in the development of and continued updating of the plan of care and ongoing changes. A comprehensive review of the plan of care must be done at the time of significant changes, at the end of hospice certification period, and or at least every ninety days, whichever is sooner.8.      The plan of care must include an assessment of the individual’s needs and identification of the services, including the management of pain and discomfort and symptom relief.9.      All problems/needs must be prioritized, with corresponding goals and anticipated dates for reaching those goals.10. Each patient must be monitored for his/her response to care or services provided against established patient goals and patient outcomes to determine if goals have been achieved.11. As needed, patients/families must receive written instructions regarding treatments or aspects of care that will be responsibility of the patient and family/caregiver to manage.12. The comprehensive plan of care must contain, but will not be limited to, the following:a.      Diagnosesb.      Assessment/identification of patient and family/caregiver needs, including physical, functional, nutritional, psychosocial, cognitive, cultural, spiritual, counseling, and educational.c.      Statement of treatment goalsd.      Individualized interventionse.      Pain and symptom managementf.        Medications and treatments, including allergiesg.      Physician ordersDuring a review of the guidance from the National Institute on Drug Abuse, titled “Benzodiazepines and Opioids,” dated 11/7/2022, the guidance indicated the following:1.      Taking opioids in combination with other CNS depressants, such as benzodiazepines (type of prescription sedative for anxiety), increases the risk of life-threatening overdose.2.      Combining opioids and benzodiazepines can cause sedation and suppress breathing—the cause of overdose fatality—in additional to impairing cognitive (mental) functions.3.      The Centers of Disease Control and Prevention (CDC) recommends that clinicians use particular caution when prescribing benzodiazepines concurrently with opioids and consider whether benefits outweigh the risks.[Source: https://nida.nih.gov/research-topics/opioids/benzodiazepines-opioids]

Based on interview and record review, the Hospice Agency (HA, agency providing specialized care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Clinical Records was met as follows: --- The Hospice Agency (HA, agency providing specialized care to terminally ill patients with six months or less to live) failed to ensure individualized care plans (CPs) were documented for six of 14 sampled patients (Patients 4, 5, 6, 7, 8, and 9) by failing to:a.    Ensure the HA nurse documented an individualized CP for Patient 4’s concurrent physician orders for morphine (powerful opioid medication to treat severe pain) and lorazepam (medication to treat anxiety [excessive worry and fear that interfere with daily life] by slowing down the central nervous system [CNS]). b.    Ensure the HA nurse documented individualized CPs for Patient 5’s concurrent physician orders for Fentanyl (powerful synthetic opioid medication 50 to 100 times more potent than Morphine to treat severe pain), lorazepam, and morphine; blood glucose (BG, blood sugar) monitoring; and Patient 5 being in “transitioning” phase (final phase of life when a person is nearing death).c.      Ensure the HA nurse documented individualized CPs for Patient 6’s BG monitoring and Patient 6’s concurrent physician orders for lorazepam, Norco (combination of acetaminophen [medication to treat mild to moderate pain] and opioid medication hydrocodone), and morphine.d.      Ensure the HA nurse documented individualized CPs to reflect Patient 7’s diagnosis of diabetes mellitus type 2 (DM II, long-term condition in which the body is unable to maintain normal BG levels) and Patient 7’s concurrent physician orders for lorazepam, morphine, and Zolpidem (prescription sleeping pill that slows down the CNS).e.      Ensure the HA nurse documented individualized CPs for the episode of very high blood pressure (BP, force of blood against the arteries with the normal BP as 120/80 millimeters of Mercury [mm Hg, unit of pressure measurement]) of 158/106 mm Hg on 8/26/2025 and that included the parameters for the Valsartan (medication to treat high BP) ordered by the physician; and Patient 8’s concurrent physician orders for Norco, alprazolam (medication to treat anxiety by slowing down the CNS), lorazepam, Morphine, and Carbidopa-Levodopa (medication to treat Parkinson’s disease [progressive neurological disorder affecting movement]).f.        Ensure the HA nurse documented individualized CPs to reflect the diagnosis of DM II and wound to the coccyx (tailbone) and Patient 9’s concurrent physician orders for hydrocodone/ibuprofen (combination of opioid and a non-steroidal anti-inflammatory drug to treat pain), lorazepam, and Morphine.These failures had the potential to cause the patients’ health status to decline due to possible inconsistent and/or incorrect medication administration and delivery of care and services related to the incomplete, inaccurate, non-individualized care plans (Refer to L672). 2.    The HA failed to ensure the documented  physician's orders for medications for one for 14 sampled patients (Patient 4) were complete, accurate, and matched the medications dispensed to the patient by the pharmacy.  This failure had the potential to result in medication errors (preventable mistakes that occur during medication administration), adverse medication effects (harmful or unintended responses to a drug), and drug interactions (another drug changes how a drugs works in the body) related to the physician orders not being followed as prescribed (Refer to L678). 3.      The HA failed to ensure complete and accurate documentation by failing to ensure the physician and spiritual counselor signed the interdisciplinary group (IDG, team composed of the Registered Nurse [RN], Medical Social Worker [MSW], spiritual counselor [SC], and physician [MD] who discuss the patients’ plan of care to provide the best individualized care and support to patients and families) notes and IDG meeting sign-in sheets for five of 14 sampled patients (Patients 4, 5, 6, 8, and 9).This failure had the potential to result in a delay in the delivery of the correct treatment and services to the patients due to the incomplete and/or unvalidated care plans (Refer to L679).The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with the federal regulations for Clinical Records to ensure accurate and complete documentation of all the care and services provided to these hospice certified patients.

Based on interviews and record review, the Hospice Agency (HA, agency providing specialized care to terminally ill patients with six months or less to live) failed to ensure the patient's clinical records contained completed individualized plans of care (POC) for six of 14 sampled patients (Patients 4, 5, 6, 7, 8, and 9) by failing to:a.    Ensure the HA nurse documented an individualized POC for Patient 4’s concurrent physician orders for morphine (powerful opioid medication to treat severe pain) and lorazepam (medication to treat anxiety [excessive worry and fear that interfere with daily life] by slowing down the central nervous system [CNS]). b.    Ensure the HA nurse documented individualized POC for Patient 5’s concurrent physician orders for Fentanyl (powerful synthetic opioid medication 50 to 100 times more potent than Morphine to treat severe pain), lorazepam, and morphine; blood glucose (BG, blood sugar) monitoring; and Patient 5 being in “transitioning” phase (final phase of life when a person is nearing death).c.      Ensure the HA nurse documented individualized POC for Patient 6’s BG monitoring and Patient 6’s concurrent physician orders for lorazepam, Norco (combination of acetaminophen [medication to treat mild to moderate pain] and opioid medication hydrocodone), and morphine.d.      Ensure the HA nurse documented individualized POC to reflect Patient 7’s diagnosis of diabetes mellitus type 2 (DM II, long-term condition in which the body is unable to maintain normal BG levels) and Patient 7’s concurrent physician orders for lorazepam, morphine, and Zolpidem (prescription sleeping pill that slows down the CNS). e.      Ensure the HA nurse documented individualized for the episode of very high blood pressure (BP, force of blood against the arteries with the normal BP as 120/80 millimeters of Mercury [mm Hg, unit of pressure measurement]) of 158/106 mm Hg on 8/26/2025 and that included the parameters for the Valsartan (medication to treat high BP) ordered by the physician; and Patient 8’s concurrent physician orders for Norco, alprazolam (medication to treat anxiety by slowing down the CNS), lorazepam, Morphine, and Carbidopa-Levodopa (medication to treat Parkinson’s disease [progressive neurological disorder affecting movement]). f.        Ensure the HA nurse documented individualized POC to reflect the diagnosis of DM II and wound to the coccyx (tailbone) and Patient 9’s concurrent physician orders for hydrocodone/ibuprofen (combination of opioid and a non-steroidal anti-inflammatory drug to treat pain), lorazepam, and Morphine.These failures had the potential to cause the patients’ health status to decline due to possible inconsistent and/or incorrect medication administration and delivery of care and services related to an incomplete, inaccurate, and non-individualized POC. --- Findings:a.      During a review of Patient 4’s profile sheet, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 4’s initial start of care (SOC) on 9/14/2025 with diagnoses that included Alzheimer’s disease (progressive brain disorder that causes memory loss and decline in mental ability) and chronic kidney disease (gradual loss of kidney function due to the kidney damage causing the inability to filter blood properly).During a review of Patient 4’s “Medicine List” as of 11/12/2025, the “Medicine List” indicated the following physician orders:1.      Lorazepam 2 mg/ml orally or under the tongue every 2 hours as needed for restlessness or agitation. Give 0.25 mL for mild anxiety and 0.5 mL for medium-high anxiety level.2.      Morphine 100 mg/5 mL orally or sublingual every 2 hours as needed for pain. Give 0.25 mL (5 mg) for pain scale 4-6 (out of 10), 0.50 mL (10 mg) for pain scale 7-8 (out of 10), 0.75 ml (15 mg) for pain scale 9-10 (out of 10), and 1 ml (20 mg) for pain scale 10/10.During an interview and a concurrent review of Patient 4’s clinical records with the Director of Patient Care Services (DPCS) on 11/17/2025 at 2:12 p.m., Patient 4’s nursing assessments, previous health history, care plans, medication list, and visit notes were reviewed. The DPCS stated there was no documented evidence that Patient 4’s care plans were individualized to reflect Patient 4’s high-risk medications. b.      During a review of Patient 5’s profile sheet, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 5’s SOC on 10/31/2025 with diagnoses that included liver cirrhosis (late stage of liver disease), hepatic encephalopathy (brain disorder caused by advanced liver disease that prevents liver from filtering toxins, like ammonia, from the blood), and diabetes mellitus (long-term condition in which the body is unable to maintain normal blood glucose [BG, blood sugar] levels).During a review of Patient 5’s “Medicine List” as of 11/13/2025, the “Medicine List” indicated the following physician orders:1.      Fentanyl 40 mg tablet 1 patch transdermal (through the skin) every 72 hours for pain2.      Lorazepam 0.5 mg orally every 6 hours for anxiety3.      Lorazepam 0.5 mg orally every 4 hours as needed for anxiety/agitation4.      Morphine 100 mg/5 ml orally or under the tongue 5 mg every 2 hours as needed for pain. Give 5 mg every 2 hours as needed for mild pain 1-3 (out of 10), 10 mg every 2 hours as needed for moderate pain 4-6 (out of 10), and 15 mg every 2 hours as needed for severe pain 7-10 (out of 10).During an interview and a concurrent record review on 11/17/2025 at 2:37 p.m. with the Director of Patient Care Services (DPCS), Patient 5’s profile sheet, visit notes, physician orders, and care plans were reviewed. The DPCS stated there was no documented evidence that Patient 5’s care plans were individualized to reflect Patient 5’s current condition, who is “transitioning” and was having blood glucose issues and Patient 5’s high-risk medications. The DPCS stated Patient 5’s care plans must be individualized to ensure all staff are aware of the treatment and services to be provided and ensure continuity of care. c.      During a review of Patient 6’s profile sheet, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 6’s SOC on 8/8/2025 with diagnoses that included liver cell cancer, malignant ascites (accumulation of fluid in the abdomen caused by cancer cells in the lining of the abdominal cavity) benign prostatic hyperplasia (non-cancerous enlargement of the prostate gland), and type 2 diabetes mellitus (DM II).During a review of Patient 6’s “Medicine List” as of 11/13/2025, the “Medicine List” indicated the following physician orders:1.      Hydrocodone 5 mg-acetaminophen 325 mg 1 tablet orally every 6 hours as needed for pain2.      Morphine 100 mg/5 ml 0.25 – 1 ml orally or under the tongue every 2 hours as needed for pain/shortness of breath. Give 0.25 ml for pain 1-3 (out of 10), 0.50 ml for pain 4-6 (out of 10), 0.75 ml for pain 7-8 (out of 10), and 1 ml for pain 9-10 (out of 10).3.      Lorazepam 2 mg/ml 0.25-1 ml orally or under the tongue every 2 hours as needed for anxiety/agitation. Give 0.25 ml for anxiety/agitation/shortness of breath. Give 0.5 ml for mild anxiety/agitation/shortness of breath. Give 0.75 ml for moderate anxiety/agitation/shortness of breath. Give 1 ml for severe anxiety/agitation/shortness of breath.During an interview and a concurrent record review on 11/17/2025 at 2:37 p.m. with the DPCS, Patient 6’s profile sheet, visit notes, physician orders, and care plans were reviewed. The DPCS stated there was no documented evidence that Patient 6’s care plans were individualized to reflect BG problem and high-risk medications. The DPCS stated Patient 6’s care plans must be based on complete and accurate assessments, including of BG levels, to ensure all staff are “aware of what’s going on” and could provide the necessary care and services required to maintain Patient 6’s comfort and well-being. d. During a review of Patient 7’s profile sheet, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 7’s SOC on 11/6/2025 with diagnoses that included Alzheimer’s disease and DM II with diabetic chronic kidney disease (diabetic complication characterized by the damage to the kidneys’ filtering system due to uncontrolled BG levels).During a review of Patient 7’s “Medicine List” as of 11/13/2025, the “Medicine List” indicated the following physician orders:1.      Lorazepam 2 mg/ml orally or under the tongue every 2 hours as needed for restlessness or agitation. Give 0.25 mL for mild anxiety and 0.5 mL for medium-high anxiety level.2.      Morphine 20 mg/1 mL orally or sublingual every 2 hours as needed for pain. Give 0.25 mL (5 mg) for pain scale 4-6 (out of 10), 0.50 mL (10 mg) for pain scale 7-8 (out of 10), 0.75 ml (15 mg) for pain scale 9-10 (out of 10), and 1 ml (20 mg) for pain scale 10/10 and call HA.3.      Zolpidem 5 mg 1 tablet at bedtime to improve sleeping. Repeat in 2 hours if the first tablet is not effective.During an interview and a concurrent record review on 11/17/2025 at 2:37 p.m. with the DPCS, Patient 7’s profile sheet, visit notes, physician orders, and care plans were reviewed. The DPCS stated there was no documented evidence that Patient 7’s care plans were not individualized to reflect DM II diagnosis and high-risk medications. The DPCS stated given the presence of a diabetic complication, Patient 7’s baseline BG levels must be assessed by the HA nurse to ensure the BG levels “do not get out of control” and affect Patient 7’s well-being. The DPCS stated hypoglycemia (low BG) could lead to confusion, coma (state of deep unconsciousness), hospitalization, and death. e. During a review of Patient 8’s profile sheet, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 8’s SOC on 8/26/2025 with diagnoses that included Parkinsonism (syndrome characterized by symptoms such as tremors, rigidity, and slowness of movement), anorexia (eating disorder characterized by a distorted body image, extreme weight loss, and intense fear of gaining weight), physical debility (state of general weakness), depression (serious mood disorder characterized by persistent sadness and/or loss of interest in activities that interfere with daily life), and anxiety disorder (excessive worry and fear that interfere with daily life).During a review of Patient 8’s “Medicine List” as of 11/13/2025, the “Medicine List” indicated the following physician orders:1.      Alprazolam 1 mg tablet orally three times a day as needed for anxiety2.      Lorazepam 2 mg/ml 0.25 ml-0.5 ml every 2 hours as needed for anxiety. Give 0.25 ml sublingually every 2 hours as needed for anxiety 3-5/10 and 0.5 ml sublingually every 2 hours as needed for anxiety of 6-10/10.3.      Hydrocodone 5 mg-acetaminophen 325 mg 1 tablet orally four times a daily as needed for pain.4.      Morphine 100 mg/5 ml 0.25 ml-1 ml every 2 hours as needed for pain. Give 0.25 ml sublingually every 2 hours as needed  for pain level 4-6 (out of 10), 0.5 ml sublingually every 2 hours as needed for pain level 7-8 (out of 10), 0.75 ml sublingually every 2 hours as needed for pain level 9-10 (out of 10). Give 1 ml sublingually every 2 hours as needed for pain level 10/10.5.      Carbidopa 10 mg-Levodopa 100 mg 1 tablet orally three times a day for Parkinson’s disease.During an interview and a concurrent record review on 11/17/2025 at 2:37 p.m. with the DPCS, Patient 8’s profile sheet, visit notes, physician orders, and care plans were reviewed. The DPCS stated there was no documented evidence that Patient 8’s care plans were individualized to reflect Patient 8’s high-risk medications and an episode of a very high BP of 158/106 mm Hg on 8/26/2025 that required the Valsartan medication order. The DPCS stated there must be an individualized care plan for high BP to include Valsartan as an intervention with the proper parameters ordered to indicate when to administer or hold the medication and call the physician. The DPCS stated it is “essential to keep the hypertension under control” to ensure Patient 8 does not experience complications, such as, stroke. f. During a review of Patient 9’s profile sheet, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 9’s SOC on 7/13/2025 with diagnoses that included Alzheimer’s disease, DM II with diabetic cataract (complication of DM II characterized by the clouding of the eye’s lens due to high BG levels) and diabetic polyneuropathy (complication of DM II characterized by nerve damage, oftentimes affecting the legs and feet, due to high BG levels).During a review of Patient 9’s “Medicine List” as of 11/13/2025, the “Medicine List” indicated the following physician orders:1.      Hydrocodone 7.5 mg – ibuprofen 200 mg 0.5 tablet orally every 12 hours as needed for pain.2.      Children’s ibuprofen 100 mg/5 ml 10 ml orally every 6 hours as needed for pain or temperature above 100.5 degrees Fahrenheit3.      Lorazepam 1 mg/0.5 ml 0.5 mg orally or under the tongue every 2 hours as needed for anxiety or agitation4.      Morphine 100 mg/5 ml 5 mg orally or under the tongue every 2 hours as needed for pain. Give 5 mg every 2 hours as needed for mild pain, 10 mg every 2 hours as needed for moderate pain, and 15 mg every 2 hours as needed for severe pain.During an interview and a concurrent record review on 11/18/2025 at 12:38 p.m. with the DPCS, Patient 9’s profile sheet, visit notes, physician orders, and care plans were reviewed. The DPCS stated there was no documented evidence that Patient 9’s care plans were individualized to reflect Patient 9’s wound, diabetes mellitus type 2 diagnosis, and high-risk medications. The DPCS stated it was important to know Patient 9’s baseline blood glucose levels because keeping them under control prevents further delay in healing of and/or worsening of Patient 9’s wound. The DPCS stated the patients’ care plans must be individualized to include the exact physician’s order for each high-risk medication and ensure its completeness and accuracy. The DPCS stated the patients’ care plans must be individualized to ensure the involvement of the patient and/or caregiver/s, ensure that all staff are aware of the risks and benefits of all the high-risk medications and goals of the treatment, and ensure all HA nurse will monitor the effectiveness of each high-risk medication. The DPCS stated it was important to ensure the care plans for the high-risk medications were individualized to prevent increased risks for adverse effects, such as excessive sedation or drowsiness that can lead to coma or death related to concurrent administration of the high-risk medications. During a review of the HA’s undated policy and procedures (P&P 1), titled “Entries into the Clinical Record,” "P&P 1" indicated the following:1.      Documentation in the clinical record must be timely, detailed, accurate, and reflect the care or services provided.2.      A clinical record must be initiated and maintained for each patient receiving care or services according to organization policies and must include at a minimum:a.      Pertinent medical historyb.      Physician orders and evidence of physician oversight activitiesc.      Changes to the plan of cared.      Dates, times, and types of interventions, assessments, and coordination of caree.      Patient response to care and services analyzed and documented as measurable goalsf.        Current patient status and progress towards goalsg.      Patient and family education3.      Entries into the clinical record must be clear, concise, and specific statements of fact.4.      All entries into the clinical record must reflect the date care was provided, month, day, and year, and must be submitted to the office within 1 business day of the date of the services.

Based on observation, interview, and record review,  the Hospice Agency (HA, agency providing specialized care to terminally ill patients with six months or less to live) failed to ensure the clinical record contained physician's orders for medications for one for 14 sampled patients (Patient 4) that were complete, accurate, and matched the medications dispensed to the patient by the pharmacy.  This failure had the potential to result in medication errors (preventable mistakes that occur during medication administration), adverse medication effects (harmful or unintended responses to a drug), and drug interactions (another drug changes how a drug works in the body) related to the physician orders not being followed as prescribed. --- Findings:During a review of Patient 4’s profile sheet, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 4’s initial start of care (SOC) on 9/14/2025 with diagnoses that included Alzheimer’s disease (progressive brain disorder that causes memory loss and decline in mental ability) and chronic kidney disease (gradual loss of kidney function due to the kidney damage causing the inability to filter blood properly).During a review of Patient 4’s “Hospice Recert Summary Report,” dated 11/5/2025, the “Hospice Recert Summary Report” indicated the following:1.      Skilled Nurse (SN) Visit once a week and as needed effective 11/13/20252.      Current physician-ordered medications include:i.        1/17/2025 – acetaminophen 650 milligrams (mg, unit of measurement of weight) 1 suppository (bullet-shaped medication to be inserted into the rectum to be dissolved) rectally every 6 hours/4 hours (physician order was not clarified) if temperature is greater than 100 degrees Fahrenheitii.      1/17/2025 – Dulcolax 10 mg 1 suppository rectally if no bowel movement (BM) is present in 48 hours. Provide it daily until BM. Hold it after the BM for 48 hours.iii.    1/30/2025 - amlodipine 2.5 mg take 1 tablet daily as needed for systolic BP (SBP, top number in a BP reading that indicates pressure in the arteries when the heart contracts) greater than 160 millimeters of Mercury (mm Hg, unit of measurement of pressure with the normal SBP less than 120 mm Hg)iv.    3/22/2025 – Robitussin nighttime cough DM 3.125 mg-7.5 mg per 5 milliliter (ml, unit of measurement of volume) oral liquid 1 tablespoon (15 ml) every 6 hours as needed for coughv.      11/10/2025 – Miralax 17 grams mixed with 8 ounces of beverage given nightly. Hold if loose stool/diarrhea observedDuring an observation and concurrent interview, while on a joint home visit at Patient 4’s living room, on 11/14/2025 at 11:30 AM, with Registered Nurse (RN) 2, Patient 4’s medication bottles, medication list at home, and active physician medication orders were reviewed. RN 2 stated the following:1.      The medication label for acetaminophen suppository was inconsistent with the physician’s order as the medication label indicated to administer 1 suppository per rectum every 6 hours as needed for temperature above 101 degrees Fahrenheit.2.      RN 2 stated the medication label for Dulcolax 10 mg suppository was inconsistent with the physician’s order as the medication label indicated to insert 1 suppository per rectum if no BM in 72 hours.3.      RN 2 stated he ordered amlodipine two weeks ago, but there was no documented evidence that it was ordered and delivered to Patient 4’s home. RN 2 stated Patient 4 had not been administered amlodipine recently, because Patient 4’s BP had not been very high for months.4.      RN 2 stated Robitussin nighttime cough DM (cough medication with dextromethorphan [cough suppressant] 30 mg per 20 ml dose and doxylamine succinate [antihistamine, antiallergy] 12.5 mg per 20 ml dose as active ingredients) was not available in Patient 4’s home as ordered by the physician, but Geri-Tussin DM (cough medication with active ingredients dextromethorphan 10 mg and Guaifenesin 100 mg [expectorant]) was filled by the pharmacy on 10/24/2025 and delivered to Patient 4’s home. RN 2 stated the medication available in Patient 4’s home was different from what was prescribed/ordered by the physician and needed to be clarified with the physician and pharmacy.5.      RN 2 stated Patient 4’s physician order for Miralax 17 grams was not yet reflected on Patient 4’s copy of the medication list at home because it was recently ordered on 11/7/2025. RN 2 did not have an updated copy of the medication list to provide to Patient 4’s caregiver/s.During an interview and a concurrent review of Patient 4’s clinical records with the Director of Patient Care Services (DPCS) on 11/17/2025 at 2:12 p.m., Patient 4’s nursing assessments, previous health history, care plans, medication list, and visit notes were reviewed. The DPCS stated the SNs must conduct a medication profile review during every home visit and provide an updated list of medications to the patient (in general) and/or caregiver/s. The DPCS stated the VNs must compare the physician’s medication orders against the updated medication list and the medication bottles to ensure that there are no discrepancies. The DPCS stated when the discrepancies were found during a SN home visit, the VNs should have notified and clarified with the physician the medication orders on acetaminophen, Dulcolax, and Robitussin. The DPCS stated although the amlodipine was ordered on an as needed basis, amlodipine must always be readily available in Patient 4’s home and ready for use by Patient 4.During a review of the HA’s undated policy and procedures (P&P), titled “Medication Profile,” the P&P indicated the following:1.      Patients receiving medications administered by the HA must have a current, accurate medication profile in the clinical record.2.      Medication profiles must be updated for each change to reflect current medications and new and/or discontinued medications.3.      A drug regimen review must be performed at the time of admission and on an ongoing basis to assist in evaluating effectiveness and appropriateness; identify potential and actual drug/food interactions; adverse reactions, and duplicate therapy and noncompliance issues.4.      During subsequent hospice visits, the medication profile must be used as a care planning and teaching guide to assure that the patient and family/caregiver, as well as other case managers, understand the medication regimen.5.      Deviations in taking medications as ordered must be documented in the clinical notes, and the physician must be notified.6.      The case manager must review the medication label for name, additional patient identifier, drug dosage, and prescription.During a review of the HA’s undated policy and procedures (P&P 1), titled “Entries into the Clinical Record,” “P&P 1” indicated the following:1.      Documentation in the clinical record must be timely, detailed, accurate, and reflect the care or services provided.2.      A clinical record must be initiated and maintained for each patient receiving care or services according to organization policies and must include at a minimum:-Pertinent medical history-Physician orders and evidence of physician oversight activities-Changes to the plan of care-Dates, times, and types of interventions, assessments, and coordination of care-Patient response to care and services analyzed and documented as measurable goals-Current patient status and progress towards goals-Patient and family education3.      Entries into the clinical record must be clear, concise, and specific statements of fact.4.      All entries into the clinical record must reflect the date care was provided, month, day, and year, and must be submitted to the office within 1 business day of the date of the services.During a review of the HA’s undated policy and procedures (P&P 2), titled “Medication Profile,” “P&P 2” indicated the following:1.      Patients receiving medications administered by the HA must have a current, accurate medication profile in the clinical record.2.      Medication profiles must be updated for each change to reflect current medications and new and/or discontinued medications.3.      A drug regimen review must be performed at the time of admission and on an ongoing basis to assist in evaluating effectiveness and appropriateness; identify potential and actual drug/food interactions; adverse reactions, and duplicate therapy and noncompliance issues.4.      During subsequent hospice visits, the medication profile must be used as a care planning and teaching guide to assure that the patient and family/caregiver, as well as other case managers, understand the medication regimen.5.      Deviations in taking medications as ordered must be documented in the clinical notes, and the physician must be notified.6.      The case manager must review the medication label for name, additional patient identifier, drug dosage, and prescription.

Based on interviews and record review, the Hospice Agency (HA, agency providing specialized care to terminally ill patients who have six months or less to live) failed to ensure the clinical record contained a complete and accurate documentation the physician and spiritual counselor signed the interdisciplinary group (IDG, team composed of the Registered Nurse [RN], Medical Social Worker [MSW], spiritual counselor [SC], and physician [MD] who discuss the patients’ plan of care to provide the best individualized care and support to patients and families) notes and IDG meeting sign-in sheets for five of 14 sampled patients (Patients 4, 5, 6, 8, and 9).This failure had the potential to result in the delayed delivery of care, treatment, and services to the patients due to no documented evidence of coordination among IDG members.. --- Findings:a.      During a review of Patient 4’s profile sheet, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 4’s initial start of care (SOC) on 9/14/2025 with diagnoses that included Alzheimer’s disease (progressive brain disorder that causes memory loss and decline in mental ability) and chronic kidney disease (gradual loss of kidney function due to the kidney damage causing the inability to filter blood properly).During a review of Patient 4’s “Hospice Recert Summary Report,” dated 11/5/2025, the “Hospice Recert Summary Report” indicated the following:-For IDG meeting note, dated 11/5/2025, MD did not sign the IDG note.-For IDG meeting notes, dated 10/17/2025, 10/3/2025, and 9/19/2026 - MD signed the IDG note on 10/31/2025.b.     During a review of Patient 5’s profile sheet, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 5’s start of care (SOC) on 10/31/2025 with diagnoses that included liver cirrhosis (late stage of liver disease), hepatic encephalopathy (brain disorder caused by advanced liver disease that prevents liver from filtering toxins, like ammonia, from the blood), and diabetes mellitus long-term condition in which the body is unable to maintain normal blood glucose [BG, blood sugar] levels.During a review of Patient 5’s “Hospice Recert Summary Report,” dated 11/5/2025, the “Hospice Recert Summary Report” indicated for the IDG meeting, dated 11/5/2025, the MD did not sign the IDG note (Electronic Signature Date left blank).c.      During a review of Patient 6’s profile sheet, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 6’s start of care (SOC) on 8/8/2025 with diagnoses that included liver cell cancer, malignant ascites (accumulation of fluid in the abdomen caused by cancer cells in the lining of the abdominal cavity) benign prostatic hyperplasia (non-cancerous enlargement of the prostate gland), and type 2 diabetes mellitus (DM II).During a review of Patient 6’s “Hospice Recert Summary Report,” dated 11/5/2025, the “Hospice Recert Summary Report” indicated the following:-For IDG meeting note, dated 11/5/2025 – MD did not sign the IDG note.-For IDG meeting notes, dated 10/22/2025, 10/8/2025, 9/24/2025, 9/10/2025, 8/27/2025, and 8/13/2025 – MD signed the IDG note on 10/31/2025.d.      During a review of Patient 8’s profile sheet, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 8’s start of care (SOC) on 8/26/2025 with diagnoses that included Parkinsonism (syndrome characterized by symptoms such as tremors, rigidity, and slowness of movement), anorexia (eating disorder characterized by a distorted body image, extreme weight loss, and intense fear of gaining weight), physical debility (state of general weakness), depression (serious mood disorder characterized by persistent sadness and/or loss of interest in activities that interfere with daily life), and anxiety disorder (excessive worry about real or perceived threats).During a review of Patient 8’s “Hospice Recert Summary Report,” dated 11/15/2025, the “Hospice Recert Summary Report” indicated the following:-For IDG meeting note, dated 11/5/2025 – MD did not sign the IDG note.-For IDG meeting notes, dated 10/22/2025, 10/8/2025, 9/24/2025, 9/10/2025, and 8/27/2025 – MD signed the IDG note on 10/31/2025.e.      During a review of Patient 9’s profile sheet, titled “Patient Information Report,” the “Patient Information Report” indicated Patient 9’s SOC on 7/13/2025 with diagnoses that included Alzheimer’s disease, DM II with diabetic cataract (complication of DM II characterized by the clouding of the eye’s lens due to high BG levels) and diabetic polyneuropathy (complication of DM II characterized by nerve damage, oftentimes affecting the legs and feet, due to high BG levels).During a review of Patient 9’s “Hospice Recert Summary Report,” dated 11/5/2025, the “Hospice Recert Summary Report” indicated for the IDG meeting, dated 11/5/2025, the MD did not sign the IDG note.During a review of Patient 9’s “Hospice Recert Summary Report,” dated 10/21/2025, the “Hospice Recert Summary Report” indicated the following:-For IDG meeting notes, dated 8/27/2025, 9/10/2025, 9/24/2025, 10/8/2025, and 10/21/2025 – MD signed the IDG notes on 10/31/2025.-For IDG meeting notes, dated 7/30/2025 and 8/13/2025, the MD did not sign the IDG note.-For IDG meeting notes, dated 7/2025 and 7/16/2025 – MD signed the IDG notes on 9/29/2025.During an interview and a concurrent review on 11/17/2025 at 2:37 p.m. with the Director of Patient Care Services (DPCS), IDG meeting sign-in sheets were reviewed. The DPCS stated the MD attended the IDG meetings via telephone and the SC attended the IDG meetings in-person every other Wednesday. The DPCS stated she signed “via phone” on the space provided for the Medical Director signature on 11/15/2025, 10/22/2025, and 10/8/2025. However, the DPCS stated there was no documented evidence that the Medical Director attended the IDG meetings, dated 9/24/2025, 9/10/2025, 8/13/2025, 7/30/2025, 7/16/2025, and 7/2/2025. In addition, the DPCS stated there was no documented evidence that the SC attended the IDG meetings, dated 10/22/2025 and 9/24/2025. The DPCS stated it was important for the MD, RN, SC, and MSW to attend the IDG meetings at least every two weeks to ensure all members of the team are all “on the same page” by being updated about what is happening to the patients, agreeing on the plan of care to be provided, and  being aware of the new physician’s orders to be carried out.During a review of the HA’s undated P&P 1, titled “Entries into the Clinical Record,” “P&P 1” indicated the following:1.      Documentation in the clinical record must be timely, detailed, accurate, and reflect the care or services provided.2.      A clinical record must be initiated and maintained for each patient receiving care or services according to organization policies and must include at a minimum:a.      Pertinent medical historyb.      Physician orders and evidence of physician oversight activitiesc.      Changes to the plan of cared.      Dates, times, and types of interventions, assessments, and coordination of caree.      Patient response to care and services analyzed and documented as measurable goalsf.        Current patient status and progress towards goalsg.      Patient and family education3.      Entries into the clinical record must be clear, concise, and specific statements of fact.4.      All entries into the clinical record must reflect the date care was provided, month, day, and year, and must be submitted to the office within 1 business day of the date of the services.During a review of the HA’s undated “P&P 2,” titled “Interdisciplinary Team Coordination of Care,” “P&P 2” indicated the following:1.      The interdisciplinary group must maintain responsibility for the provision and coordination of care, regardless of the setting where care is provided to its patients.2.      Written evidence of care coordination must be found in the plan of care and/or interdisciplinary team meeting forms in the patient’s clinical record and must involve the patient’s attending physician.3.      The IDG must conduct assessments, develop and update the plan of care, and review the effectiveness of care a minimum of every two weeks. The attending physician must receive a copy of the care plan updates.4.      All IDG members, including those providing contracted services, must have access to the plan of care to ensure coordination and continuity of care.

Observed in Regulatory Review. In 2 of 10 patient records reviewed, In RR #4 it was noted that there was no specific order for the name or type of enteral feeding the patient was receiving at 50cc/hr Also there was no specific order for the size of the tracheostomy tube or specifics for tracheostomy care This was confirmed by the Director of Nursing . Observed in Record Review. It was noted that In HV #1 the hospice care plan order was not clarified. The order stated Change the foley catheter monthly The size of the foley was not listed or clarified for several certification periods. This was noted by the Director of Patient Care.

Observed in Record Review. It was noted HV #3 that there were two missed RN visits, however there was no documentation of why the visits were missed, no mention of missed visits in the IDG notes or the Plan of Care . This was confirmed by the Director of Nursing

Observed in Patient Home. On HV#3 it was noted that the Hospice aide was wearing gloves to do a complete shower for the patient. However after the aide cleansed the perianal area , she donned a new glove over the glove on the right hand. She then proceeded to finish the rinsing of the patient and she applied lotion to the patient's legs, back and arms and dressed the patient with both gloved hands. This confirmed by the aide and the Director of Patient Care .

Observed in Record Review. There was no documented supervision for one home health aide for 18 days. This was confirmed the Director of Patient Services.

Observed in Record Review. On 3 of 3 patient record reviewed, the Hospice surveyor noted the goals in patient records were not time specific or measurable to the intervention and care needs of the patient. For example, in HV#1, the patient had an active wound that was being treated but there were no goals related to the wound. On review of RR #2 and RR #3, all the goals were initial admission teaching goals with no timeframe for completion. For example, patient will understand when to use PRN medications but there is no timeframe for the goal. This finding was discussed and reviewed with the Director.

Observed in Patient Home. In 1 of 1 home visits conducted where reusable medical equipment was used, the clinicians failed to follow the organization's Bag Technique Policy No 7-014.1 for cleaning equipment: alcohol for stethoscope, soap and water for thermometer, and manufacturer's recommendation for blood pressure cuffs . During HV#1 the Registered Nurse used a Sani-Cloth to clean blood pressure cuff, an electronic thermometer, and a pulse oximeter. This was finding was reviewed and discussed with the Administrator.

Observed in Record Review. In 1 of 3 patient records reviewed, the assessment did not include spiritual assessment. The agency policy, Initial Assessment/Comprehensive Assessment policy (2-029.2) states the assessment will include Pt/Family spiritual orientation, including their desire for the involvement of a religious group. In RR #3, the surveyor noted the patient/family did not respond to chaplain phone call to schedule a chaplain visit and the nursing assessment had no spiritual assessment. This was reviewed and validated with the administrator.

Observed in Patient Home. In 1 of 1 home visits conducted, the patients home medication list was not accurate or updated. During HV #1, the Hospice Surveyor observed that multiple medications were not present in the home but were documented as active on the medication list. These inaccuracies included Prochlorperazine, Albuterol and Senna S. The caregiver stated the Albuterol has not been used since last year when patient had COVID and no one could find or remember last time Senna S was used. The nurse stated the patient the prochlorperazine was no longer being used and the patient now has Ondansetron 4mg supp which was in the home and prescription was dated January 2023 but not been updated on the medication record. This finding was reviewed and validated with the Administrator.

Observed in Individual Tracer. The Surveyor noted the Emergency Operation’s Plan was not reviewed and updated annually as evidenced by the organization was not able to produce documentation at the time of survey. This was reviewed and validated with the Administrator.

Observed in Individual Tracer. The Surveyor noted the Emergency Operation’s Plan had not been updated in approximately 2 and 1/2 years to include documentation of potential newly identified risks in the community that could impact the organization’s ability to provide care for its patient’s as evidenced by the organization was not able to produce documentation of this at the time of survey. This was validated with the Administrator Observed in Individual Tracer. The Surveyor noted the organization had not updated in writing the potential emergencies that could affect its ability to provide services during the past 2 and 1/2 years. This was validated with the Administrator

Observed in Individual Tracer. The Surveyor noted as part of its communication plan, the organization did not maintain the names and contact information of staff, physician volunteers, and other response partners contracted entities, and relevant federal, state, tribal, regional, and local emergency preparedness staff as evidenced by multiple employee changes including the Administrator and Director of Patient Care Services have occurred in the organization since the documented updates to the plan approximately 2 and 1/2 years ago. This was validated with the Administrator.

Observed in HR File Review. In 9 of 9 HR Files reviewed, there was no documentation to support that emergency preparedness training was provided to staff. For example the most recent emergency preparedness training documented occurred in 2018. This was reviewed and validated with the Administrator.

Observed in Record Review. In 1 of 2 records reviewed where the patient revoked hospice care, there was no revocation statement found. Identified in RR#8, the patient revoked hospice care to seek aggressive treatment. There was no documentation of a visit when the revocation statement was signed and the document was not located in the organization's electronic or paper record. This was discussed and validated with the Administrator.

Observed in Patient Home. In 1 of 1 home visits conducted with a Registered Nurse (RN) the patient's assessment was incomplete in accordance to organizational Policy No. 2-030.1,2 Ongoing Assessment. Observed in HV#1, the RN completed vital signs, heart and lung sounds, and examined the patient's lower extremities, providing minor wound care, but did not complete all assessment criteria as outlined in the organizational policy. This was discussed and validated with the Administrator following the visit.

Observed in Record Review. In 1 of 7 active patient charts reviewed, the initial psychosocial evaluation was not completed within the expected 5-day time frame. Identified in RR#1, the Medical Social Worker did not complete the Initial Comprehensive Psychosocial evaluation until 6 days following the start of care. This was discussed and validated with the Administrator. Observed in Record Review. In 2 of 11 patient records reviewed, the Pre-Bereavement Risk Assessment was completed outside the defined time frame of 5 days following the start of care. Identified in RR#1, the Medical Social Worker did not complete the Pre-Bereavement Assessment until 18 days after the start of care. Identified in RR#8, the Medical Social Worker did not complete the Pre-Bereavement Assessment until 9 days after the start of care. This was reviewed and validated with the Administrator.

Observed in Record Review. In 2 of 11 patient records reviewed, the Pre-Bereavement Risk Assessment was not completed during the initial comprehensive assessment at the start of care. Identified in RR#2, the Medical Social Worker documented yes to completing the assessment in the initial psychosocial evaluation documentation, but there was no assessment of risk factors or risk level found in the Electronic Medical Record's Bereavement Activity Console. In RR#5, the Medical Social Worker did not complete the assessment for the patient's bereaved when the patient was readmitted into the second benefit period, instead utilizing the risk assessment that was completed approximately three months earlier when the patient was admitted into the first benefit period. This was reviewed and validated with the Administrator.

Observed in Record Review. In 1 of 7 active patient records reviewed, the comprehensive 15-day assessment was not completed as required to update the plan of care. Identified in the record review for HV#2, approximately 6 weeks prior to the survey, there were 22 days between the comprehensive assessments by a Registered Nurse. This was discussed and validated by the Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not maintain an accurate patient record. For example, during HV#1 the Administrator and Surveyor arrived to the patient's home address of record to learn that the patient had moved to a Board and Care residential home. Upon arrival to the new location, it was learned that the patient had relocated to the Board and Care sometime last year. This was discussed and validated with the Administrator.

Observed in Patient Home. In 1 of 2 home visits conducted with skilled nurses, education on the safe and effective use of medications was not provided. For example, in HV#1 it was identified that the patient was receiving CBD gummies as a supplement being provided by the family. This had not been added to the plan of care, and there was no physician received. Observed during the home observation of HV#1, the Registered Nurse did not provide education to the caregiver on possible drug interactions with the patient's other medications which included narcotics and anti-anxiety medications included in the plan of care and listed on the (MAR). This was discussed and validated with the Administrator following the visits.

Observed in Record Review. In 8 of 11 records reviewed, the written plans of care were not complete to meet the patients' needs identified. For example, in the record review for HV#1, the written plan of care included problems: Altered Neurological Status and Coping/Psychosocial Issues, each without goals, interventions, or timeframes. In the record review for HV#2, the written plan of care included problems: Altered Cardiopulmonary status, and Pain/Altered Comfort, each without goals, interventions, or timeframes. In the record review for HV#3, the written plan of care included problems: Need for O2 Sats., and Altered Neurological status, each without goals, interventions, or timeframes defined. In RR#1, the written plan of care included the problem: Altered Nutrition, without goals, interventions or timeframes defined. In RR#2 the written plan of care included problems: Altered Gastrointestinal status, and Pain/Altered Comfort, without goals, interventions, or timeframes defined. In RR#4 the written plan of care included problems: Pain/Altered comfort and Altered Skin Integrity with no goals, interventions, or timeframes defined. In RR#5, the written plan of care included: Need for Continuous Care with no goals, interventions, or timeframes defined. In RR#6, the written plan of care included problems: Altered Cardiovascular Status with no defined goals, interventions, or timeframes.

Observed in Record Review. In 4 of 7 active patient records reviewed, there was no documentation of progress toward goals in the Registered Nurses' written plan of care. For each of the 4 records, the plan of care at the start of care included the problem, Need for Medical Social Worker. To date there remains no update to that problem in any of the 4 records. For example in the record review for HV#1, that problem was identified approximately 2 1/2 years prior to the survey date; in the record review for HV#2, that problem was identified at the start of care 21 months prior to the survey date; in the record review for HV#3, that problem was identified at start of care 12 months prior to the survey; in RR#1, that problem was identified at the start of care approximately 4 months prior to the survey date,. This was discussed and validate with the Administrator.

Observed in Patient Home. In 1 of 2 home visit observations conducted where medications were reviewed, there was a supplement not ordered by the physician and not included in the plan of care. Observed in HV#1, the patient was receiving CBD gummies provided by a family member as supplemental treatment for anxiety. Upon review of the record for HV#1, there was no order or inclusion into the plan of care. This was reviewed and validated with the Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted where oxygen therapy was ordered as needed, care was not provided according to the hospice plan of care. Observed during HV#1, the Registered Nurse (RN) assessed the patient's oxygen saturation at 84 percent. After several attempts by the RN to warm up the patient's fingers, and manipulating direction and placement of the oximeter on alternating fingers, the RN stopped the oxygen saturation assessment, stating that is not her rate, and, last visit the rate was 89 percent. During the assessment, the oxygen concentrator was at the patient's bedside for supplemental oxygen as needed for O2 sats. below 89% or dyspnea. The RN failed to administer oxygen to assess potential improvement in patient's condition and/or to update the plan of care. This was discussed and validated with the Administrator.

Observed in Patient Home. In 3 of 3 home visits conducted where reusable medical equipment was used, the clinicians failed to follow the organization's Bag Technique Policy No 7-014.1 for cleaning equipment: alcohol for stethoscope, soap and water for thermometer, and manufacturer's recommendation for blood pressure cuffs . For example, in HV#1 the Registered Nurse used a Sani-Cloth to clean an electronic wrist blood pressure cuff, a stethoscope, an electronic thermometer, and a pulse oximeter. In HV#2 the Licensed Vocational Nurse (LVN) used a Sani-Cloth to clean the manual blood pressure cuff, pulse oximeter, electronic thermometer, and stethoscope. The LVN also used an unlabeled cleaning cloth from a plastic sandwich type bag to clean the tablet device. In HV#3, the Hospice Aide used a Sani-Cloth to clean the electronic temple thermometer. This was discussed and validated with the Administrator. Observed in Patient Home. In 3 of 3 home visits conducted, the clinicians did not follow the organizational Bag Technique Policy No. 7.014.1 which states: 3) After hand washing, supplies and/or equipment needed for the visit will be removed from the bag. 5) When the visit is completed, reusable equipment will e cleaned..., hands will be washed, and equipment and supplies will be returned to the bag.. This practice was not followed as observed in HV#1, the Registered Nurse went into the clean area of the bag several times without performing hand hygiene, once to retrieve a stethoscope, once to retrieve a pair of gloves for wound care, and another after completing vital signs. In HV#2, the Licensed Practical Nurse went in and out of the bag wearing gloves and never performing hand hygiene during and after completing the patients assessment including to retrieve a stethoscope, a cell phone, and a tablet device for documentation. In Home Visit #3, the Hospice Aide did not perform hand hygiene after taking the patient's temperature and re-entering the bag to retrieve cleaning cloths. This was discussed with the Administrator following the visit. Observed in Patient Home. In 2 of 3 home visits conducted, the clinicians did not utilize standard precautions to prevent infection in accordance to organizational Hand Hygiene Policy No. 7-009.2 which states: 3) Hand decontamination using an alcohol-based hand rub should be performed: before having direct contact with patients; before donning sterile gloves . . . , after contact with a patient's intact skin; after contact with body fluids . . . ; when moving from a contaminated body site to a clean body site during patient care; after contact with inanimate objects including medical equipment . . .; after removing gloves. This practice was not followed as observed in HV#1 the Registered Nurse did not perform hand hygiene at multiple required opportunities to do so including: following the completion of the patient's vital signs; prior to donning gloves to perform wound care; and, prior to cleaning the reusable medical equipment. In HV#2, it was observed that the Licensed Vocational Nurse did not perform hand hygiene at multiple required opportunities including: in between changing gloves during the patient's assessment; before and after using her cell phone to time the patient's respiratory rate; upon completion of the patient's assessment; and, prior to completing a medication reconciliation.

Observed in HR File Review. In 1 of 1 Hospice Aide personnel file reviewed, it was identified that only 2 hours of in-service training was provided over the past 12 months. This was reviewed and validated with the Administrator.

Observed in Record Review. In 1 of 7 active patient records reviewed, the hospice aide supervisory visit was not completed as required at a minimum of every 14 days. Identified during the record review for HV#2, there were two occurrences where the aide supervisory visit was missed or late. The first occurred approximately 38 days prior to the survey, and the second occurred 4 days prior to the survey. This was discussed and validated with the Administrator.

Observed in Individual Tracer. Identified during the survey, there has been no volunteer recruitment efforts made since March of 2020, nor has there been any active volunteers providing services. This was reviewed and validated with the Administrator.

Observed in Individual Tracer. Identified during the survey, there has been no documentation of cost savings for services provided by volunteers in the past two years. This was reviewed and validated with the Administrator.

Observed in Individual Tracer. Identified during the survey, the agency did not meet the 5% cost savings of patient care hours for the past 2 and 1/2 years. This was reviewed and validated with the Administrator.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: 418.113, Emergency Preparedness; 418.54, Initial and comprehensive assessment of the patient; 418.56, Interdisciplinary Group, Care Planning, and Coordination of Services; and, 418.78 Volunteers. This was reviewed and validated with the Administrator.

Observed in HR File Review. In 7 of 7 personnel files reviewed where the hire date was greater than three years prior to survey, there was no evidence that in-service training or education over the past three years. For example, it was identified during the personnel record review that there was no training on OSHA Blood Born Pathogens over the past three years. Also identified during the personnel record review was that the last documented re-training on HIPAA compliance occurred in May of 2019. This was reviewed and validated with the Administrator Observed in HR File Review. In 8 of 9 HR files where personnel were eligible for annual competencies, there was no documentation to support that competencies were assessed during the past three years per Policy No 3-004.1, Annual Core Competence: Hospice personnel will demonstrate proficiency in the performance criteria/skills . . .at least annually. . . This was reviewed and validated with the Administrator

Observed in Patient Home. In 2 of 2 home visits conducted where medication reconciliations were completed, the patients home medication lists were not accurate nor updated. For example, in HV#1 it was observed that multiple medications were not present in the home but were documented as active on the medication administration record (MAR) printed the day of the home visit. These inaccuracies included the following medications on the current MAR but not in the patient’s home medication: Alprazolam 0.5 mg tablet, 1 tablet twice daily; Amlodipine 2.5 mg tablet daily; Ativan 1mg tablet ordered to take as directed, but patient was taking 0.5mg tablet 3 times daily as needed; Tramadol 50mg tablet every 6 hours as needed for pain; and, Trazodone 150 mg tablet at bedtime. Additionally, CBD gummies 1000mg CBD were being given as needed for anxiety, but were not on the MAR. In HV#2, it was observed that the patient's medication list was inaccurate and had not been updated to reflect changes in the patient's condition. For example, the MAR printed the day of the home visit included: Paxlovid 300 mg-100 mg tablet per instructions had not been discontinued from the MAR following covid-19 treatment approximately two months prior; and Sulfasalazine 50 mg tablets, 1 tablet twice daily was found in the home but not on the current MAR. This was discussed and validated with the Administrator following the visits.