Every finding on record at Victory Hospice Care, Inc

Observed in Record Review. In 3 of 10 active patient records reviewed, the organization failed to maintain an accurate record. On RRHV #2, it was noted in aide visit documentation that they were documenting that patient was on the PRN oxygen but it was observed during the home visit there oxygen was not in use. On RRHV #3, it was noted that the aide delegation sheet delegated and aide notes document use of a urinal for a female patient that is incontinent. The Aide is also documenting the oxygen when the patient is not using oxygen. On RRNHV #2, the aide is also documenting the oxygen when the patient is not using oxygen. This finding was reviewed and validated with Hospice leadership.

Observed in Record Review. In 9 of 10 active patient records reviewed, the organization failed to plan the patient's care. On review of RRHV #1, plan of care had not been updated to reflect teaching goals achievement on a patient admitted 2 months ago. On RRHV #2, it was noted that the plan of care had not been revised to reflect changes with examples of goal for improving ambulating with minimum assist when it is assessed that patient has declined to bed bound and full assist. On RRHV #3, teaching goals for hospice philosophy are still on the plan of care from admission 8 months ago. On RRNHV #1 it was noted goals not updated to reflect current assessment with example of teaching goals for hospice philosophy from admit 2 months ago still on plan of care. On RRNHV #2, patient had goal to decrease nausea that was written on admission but there has been over the last month of nausea and the goal has not been achieved to reflect current condition. On RRNHV #3, the patient goals have not been updated to reflect current assessment with example of admission teaching goals still present 3 months after admission. On RRNHV #4, the patient goals have not been updated to reflect current assessment with example of admission teaching goals still present 4 months after admission. On RRNHV #5, patient was having ongoing pain issues with changes to medications, but goal had not been updated to reflect new medications and the teaching needs to those medications. On RRNHV #7, the patient had changes to heart medications, but the goals had not been updated to reflect new medication and teaching needs for the new medications. This finding was reviewed and validated with Hospice leadership.

Observed in Record Review. In 2 of 2 bereavement records reviewed, the hospice organization did not provide care and services per the bereavement plan of care including mailings at 1,3,6,9 and 12 months. On RRBR #1, the EMR documents that the 1,3,6 and 9 months were all sent 2 days a ago on a patient who passed away 9 months ago. On RRBR #2, the EMR documents that the 1,3, and 6 months were all sent 2 days ago on a patient who passed away 6 months ago. This finding was reviewed and validated with Hospice leadership.

Observed in Record Review. On 1 of 10 active patient records reviewed, wound assessments were not documented per policy. Agency wound assessment policy states that wounds will be measured at least once every 2 weeks by the RN. On RRNHV #4 it was noted that patient has multiple wounds measurements that had not been documented in the last 2 months. This finding was reviewed and validated with Hospice leadership.

Observed in Record Review. In 3 of 10 active patient records reviewed, all entries in the medical record were not appropriately authenticated and dated in accordance with policy and currently accepted standards of practice. Agency policy (5.006) for Entries in the Medical Record states that records will be signed and made in the medical record within 7 days. In RRNHV #1 and RRNHV #2, the surveyor noted that aide assignment that was done 2 months ago has not been appropriately authenticated with signature and time stamp of electronic signature. On RRNHV #3, surveyor noted that aide assignment that was done 6 months ago has not been appropriately authenticated with signature and time stamp of electronic signature. This was reviewed and validated with the Hospice leadership.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Conditions of Participation (the terms healthcare organizations must meet to participate in federally funded healthcare programs) regarding Patients Rights was met as follows: --- 1. The HA failed to ensure that three of fourteen sampled patients (Patient 1, Patient 8, and Patient 9) had access to their plan of care at all times. (Refer to L513). 2. The HA failed to inform one of fourteen sampled patients (Patient 9) about the scope of services the HA will provide and the limitations of these services. (Refer to L519) The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutorily mandated Federal compliance for Patients Rights to ensure their rights are not violated and that they receive the highest quality of hospice care.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure that three of fourteen sampled patients (Patient 1, Patient 8, and Patient 9) had access to their plan of care at all times. This deficient practice had the potential to result in the patient and/or their family member/caregiver to be unable to be an active participant in his/her care. --- a. During a review of Patient 1s Personal Information, the Personal Information indicated that Patient 1 was admitted to the HA on 10/12/2023 with a primary diagnosis of Alzheimers disease (a progressive, irreversible brain disorder that destroys nerve cells and damages the brain, which causes a gradual decline in memory, thinking, and behavior). During a joint home visit to Patient 1s residence with Licensed Vocational Nurse 1 (LVN 1) on 10/23/2024 at 11 a.m., observed Patient 1 lying in bed, awake and alert. LVN 1 stated he had never seen Patient 1 before. Patient 1s son (FM 1), who acted as her primary caregiver, was observing the visit through video on a cellular phone. Patient 1s daughter and granddaughter (FM 2) were present at the residence during the home visit. During a review of Patient 1s home folder with LVN 1 at 11:50 a.m., as part of the home visit, it was noted the HA did not provide Patient 1 with a copy of the Plan of Care (POC, a document that maps out needs and services supplied for a Medicare patient facing a terminal illness, as well as the patient's family/caregiver). During an interview with LVN 1 on 10/23/2024 at 12:20 p.m., LVN 1 stated it was important that patients and their family be provided with a copy of the POC, so they would be aware of the goals and interventions for the patient and could also give their input. LVN 1 stated by providing a copy of the POC, both the HA and the patient would be on the same page. During a review of a document provided by the HA on 10/24/2024, titled ";Patient Home Binder Checklist," undated, the document indicated that updated plan of care summary was part of the patient home binder content. b. A review of Patient 8s untitled admission sheet, indicated a start of care date on 8/15/2024 with a primary diagnosis of malignant neoplasm (refers to an abnormal growth of tissue and is cancerous and is likely to spread (metastasize) beyond its point of origin) of unspecified part of left bronchus (A large airway that leads from the trachea (windpipe) to a lung) or lung. During a joint home visit with the Director of Patient Care Services (DPCS) on 10/23/2024 at 10:15 a.m., Patient 8 was observed sitting on the sofa, awake, alert, and oriented. Patient 8 appears weak and stated he does not want to talk too much as it is difficult for him. During a review of Patient 8s hospice folder with DPCS at 10:30 a.m., the Hospice Agency (HA) did not provide Patient 8 with a copy of the Plan of Care (POC, a document that maps out needs and services supplied for a Medicare patient facing a terminal illness, as well as the patient's family/caregiver). During interview with DPCS at 10:41 a.m., he stated that he does not know if the POC was provided to patients. DPCS stated that it is important that patients have a copy of POC since they are part of formulating the care plan, to be actively involved and is readily available for their references during their hospice stay. c. A review of Patient 9s untitled admission sheet, indicated a start of care date on 9/8/2024 with a primary diagnosis of Anorexia (an eating disorder that causes to weigh less than is considered healthy for their age and height, usually by excessive weight loss). During a joint home visit with the Director of Patient Care Services (DPCS) on 10/23/2024 at 11:17 a.m., Patient 9 was observed resting on her bed, awake and confused, Patient 9s daughter (Family Member/FM4) stated that her mother is bed ridden and only responds when name was called. During a review of Patient 9s hospice folder with DPCS at 11:30 a.m., the Hospice Agency (HA) did not provide Patient 9 with a copy of the Plan of Care (POC, a document that maps out needs and services supplied for a Medicare patient facing a terminal illness, as well as the patient's family/caregiver).During interview with FM4, she stated that she is unsure if copy of Patient 9s POC was provided to them, stated that it would be better if they will also have a copy for their reference. During interview with DPCS at 11:51 a.m., he stated that he does not know if the POC was provided to patients. DPCS stated that it is important that patients have a copy of POC since they are part of formulating the care plan, to be actively involved and is readily available for their references during their hospice stay. During a review of the agencys policy and procedure (P&P) titled ";Rights/Responsibilities", dated November 2022, the procedure indicated the patient, authorized decision-maker or legal representative will be informed during the initial assessment visit, in advance of furnishing care, of: which include H. The right to be informed of his/her condition, to participate in all aspects of care including development on their plan of care, and the right to refuse all or part of his/her care to the extent permitted by law.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to inform one of fourteen sampled patients (Patient 9) about the scope of services the HA will provide and the limitations of these services. This deficient practice resulted for Patient 9/Patient 9s family member/caregiver not being fully informed about the purpose of the hospice care services as a patient of the HA. --- A review of Patient 9s untitled admission sheet, indicated a start of care date of 9/8/2024 with a primary diagnosis of anorexia (an eating disorder that causes to weigh less than is considered healthy for their age and height, usually by excessive weight loss). During a review of Patient 9's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form, dated 10/11/2024, indicated the frequency of the skilled nurse (SN) to one visit per week, the spiritual counselor (SC) and social worker (MSW) to visit one time then prn (pro re nata, as needed). Hospice aide and volunteer services were declined. During a joint home visit with the Director of Patient Care Services (DPCS) on 10/23/2024 at 11:17 a.m., Patient 9 was observed resting on her bed, awake and confused. Patient 9s daughter (Family Member/FM4) stated that her mother is bed ridden, confused and only responds when her name was called. During an interview with FM4 at 11:45 a.m., she stated that she is the authorized representative of her mother (Patient 9) and stated that she is unsure if the admitting nurse explained to her regarding what hospice care is all about and what are the scopes and extent of services the HA can provide. FM4 stated that although her mother (Patient 9) is 101 years old and bed ridden, she does not have terminal illness and was not actively dying, and that she signed up for hospice care because she was told by HA nurse that her mother (Patient 9) can be supervised, check her health condition, be visited by a nurse once a week to monitor her vital signs, laboratory blood tests and x rays (used to generate images of tissues and structures inside the body) can be done at their home. FM4 stated that her mother (Patient 9) has recurrent UTI (Urinary Tract Infection, a condition in which bacteria invade and grow in the urinary tract) and is failing to thrive with her weight and diet. FM4 stated that if her mother (Patient 9) has a change of condition, she will bring her mother to the emergency department for further treatment. FM4 stated that her mother sees a cardiologist (doctor that specialized in heart and blood vessels problems) once a month and sees her primary doctor every other month. FM4 stated that both doctors know that her mother is under hospice care. FM4 stated that she knows that her mother is only getting palliative (specialized medical care that focuses on providing relief from pain and other symptoms of serious illness) and home health care (medical services provided at home to treat chronic health condition) but not hospice care for those patients who had six months or less to live as the HA did not explain it to her. During an interview on 10/25/2024, at 12:20 p.m., with the Director of Patient Care Services (DPCS), DPCS stated that FM4 signed the informed consent on behalf of her mother (Patient 9). The DPCS stated that during admission, it was explained to FM3 the services that they can provide and its limitations. DPCS stated that he does not know that FM4s understanding regarding hospice services were different from what has been explained to her during admission. The DPCS stated that patients and their families have the right to seek aggressive treatments and it was explained to them that it could conflict with the hospice principles and may cause a revocation. During a review of the agencys policy and procedure (P&P) titled ";Rights/Responsibilities", dated November 2022, the procedure indicated the patient, authorized decision-maker or legal representative will be informed during the initial assessment visit, in advance of furnishing care, of which include: B. The hospice philosophy and program of care. F. The goals of hospice, the interventions that support those goals and the identification of the staff providing service. H. The right to be informed of his/her condition, to participate in all aspects of care including development on their plan of care, and the right to refuse all or part of his/her care to the extent permitted by law.

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients) failed to ensure the Condition of Participation (condition that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs) for Initial and Comprehensive Assessment of the patient was met as follows: --- 1. The HA failed to conduct an updated comprehensive assessment for one of fourteen sampled patients (Patient 1) related to the changes in the patients skin. (Refer to L533). This deficient practice resulted in Patient 1s skin problem being unmonitored and necessary treatment delayed. 2. The HA failed to include the weight and mid-arm circumference (a measurement of the muscle and fat in the upper arm; it is a tool used to assess nutritional status and body composition) in the initial comprehensive assessment for Patient 9, and oxygen saturation (a measure of the amount of oxygen in a person's blood) and level of exertion (a subjective measure of how hard a person finds physical activity) for Patient 10 and 11. (Refer to L524). This deficient practice had the potential to cause patients weight unmonitored, needs not met, and delayed patient care. The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated (State Law) compliance with Federal Regulations for Initial and Comprehensive Assessment of Patient to ensure the highest quality health care is provided to patients assessed to receive hospice services.

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to include the weight and mid-arm circumference (a measurement of the muscle and fat in the upper arm; it is a tool used to assess nutritional status and body composition) in the initial comprehensive assessment for Patient 9, and oxygen saturation (a measure of the amount of oxygen in a person's blood) with level of exertion (a subjective measure of how hard a person finds physical activity) for Patient 10 and 11. This deficient practice had the potential to cause patients weight unmonitored, inaccurate assessment, and delayed patient care. --- A. During a review of Patient 9s untitled admission sheet, it indicated a start of care date of 9/8/2024 with a primary diagnosis of anorexia (an eating disorder that causes to weigh less than is considered healthy for their age and height, usually by excessive weight loss). During a review of Patient 9's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form, dated 10/11/2024, indicated the frequency of the skilled nurse (SN) to one visit per week, the spiritual counselor (SC) and social worker (MSW) to visit one time then prn (pro re nata, as needed). Hospice aide and volunteer services were declined. During a joint home visit with the Director of Patient Care Services (DPCS) on 10/23/2024 at 11:17 a.m., Patient 9 was observed resting on her bed, awake and confused. Patient 9s daughter (Family Member/FM4) stated that her mother is bed ridden and only responds when her name was called. During an observation, the DPCS performed hand hygiene, conducted an assessment of Patient 9 and took her vital signs, but did not perform a MAC measurement or weight check. During a concurrent interview and record review on 10/25/2024 at 10:43 a.m., with the Director of Patient Care Services (DPCS), Patient 9s ";LCD (Local Coverage Determination, is a decision made by a Medicare Administrative Contractor (MAC) on whether a particular service or item is reasonable and necessary, and therefore covered by Medicare within the specific jurisdiction that the MAC oversees) Hospice Eligibility Determination," dated 9/8/2024 was reviewed. The LCD indicated, in documented history/progression of at least any of the following under f. Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin (measures the amount of this protein in the clear liquid portion of the blood.) < (less than) 2.5 gram per deciliter (gm/dl) was marked as ";Yes." The DPCS stated that Patient 9s previous hospital records will support this LCDs questionnaire. During a concurrent review with the DPCS of the following: A. Patient 9s previous hospital records dated 6/11/2024 indicated ";There is no height or weight on file to calculate Patient 9s BMI (Body Mass Index, a medical screening tool that measures the ratio of height and weight to estimate the amount of body fat). B. Patient 9s previous hospital records dated 9/5/2024, indicated an albumin level of 3.1 as of 8/27/2024. The DPCS confirmed and stated that based on the information from Patient 9s previous hospital records, it does not support nor reflect if Patient 9 had a 10% weight loss or had a serum albumin <2.5gm/dl. The DPCS stated that section 2(f.) from the LCD should have not marked ";Yes", and the hospital records should have been reviewed first by the clinicians to support it. The DPCS stated that the LCD was supposed to be completed by the medical doctor with the assistance provided by nurses. During a concurrent review with the DPCS of the following: A. Patient 9s ";Current Treatment/Medication/DME (Durable Medical Equipment) List," dated 9/8/2024, indicated an order that the ";Skilled Nurse may check MAC as needed." B. Patient 9s ";Comprehensive Nursing Assessment," dated 9/8/2024, indicated no documentation of MAC or weight. C. Patient 9s ";Visit Note LVN (Licensed Vocational Nurse)," dated 9/22/2024, 10/6/2024 and 10/20/2024, indicated no documentation of MAC or weight. The DPCS confirmed that there were no documented MAC nor weight for Patient 9. The DPCS stated that it is important that a baseline MAC or weight was documented in the comprehensive nursing assessment since it was the initial visit made for Patient 9. The DPCS stated that the MAC or weight should have been checked and documented by the visiting nurses in order to monitor if Patient 9 was continuously losing weight or improving. The DPCS stated that the IDG and health care team involved in Patient 9s care will not be able to determine if any weight changed occurred if no MAC or weight documented. B. During a review of Patient 10s untitled admission sheet, it indicated a start of care date on 3/29/2024 with a primary diagnosis of bronchiectasis (a condition that occurs when the tubes that carry air in and out of your lungs get damaged, causing them to widen and become loose and scarred) uncomplicated. During a review of Patient 10's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form, dated 9/27/2024, indicated the frequency of the skilled nurse (SN) to one visit per week, the spiritual counselor (SC) and social worker (MSW) to visit one time then prn (pro re nata, as needed). Hospice aide and volunteer services were declined. During a concurrent interview and record review on 10/25/2024 at 11:30 a.m., with the Director of Patient Care Services (DPCS), Patient 10s ";LCD (Local Coverage Determination, is a decision made by a Medicare Administrative Contractor (MAC) on whether a particular service or item is reasonable and necessary, and therefore covered by Medicare within the specific jurisdiction that the MAC oversees) Hospice Eligibility Determination," dated 9/13/2024 was reviewed. The LCD indicated the following: 1. Section 2. Hypoxia (low levels of oxygen in your body tissues). 2. Under b. O2 (Oxygen) saturation (a measurement of how much oxygen in blood is carrying as a percentage of the maximum it could carry) less than or equal to 88% determined either by arterial blood gases (measures the balance of oxygen and carbon dioxide in the blood to see how well lungs are working) or O2 saturation monitors? was marked as ";Yes." The DPCS stated that Patient 10s previous hospital records will support this LCDs questionnaire. During a concurrent review with the DPCS, Patient 10s previous hospital records dated 3/27/2024 indicated the ";Patient was also on oxygen in the hospital, with a goal of > (greater than) 90%, 90%-92% is normal." The DPCS confirmed and stated that based on the information from Patient 10s previous hospital records, it does not support nor reflect if Patient 10 had O2 saturation of 88% or less. The DPCS stated that section b. questionnaire from the LCD should have not marked ";Yes", and hospital records should have been reviewed first by the clinicians to support it. The DPCS stated that the LCD was supposed to be completed by the medical doctor with the assistance provided by nurses. During a concurrent review with the DPCS of the following: A. Patient 10s ";Re-Cert Assessment," dated 9/13/2024, indicated a documentation of an O2 Sat of 97% on room air (RA). B. Patient 10s ";Visit Note LVN (Licensed Vocational Nurse)," dated 10/14/2024 - indicated a documentation of an O2 Sat of 97% on RA. 10/19/2024 - indicated a documentation of O2 Sat of 98% on RA and 10/21/2024 - indicated documentation of an O2 Sat of 98% on RA. The DPCS confirmed that Patient 10s O2 saturation was greater than (>) 88%. The DPCS stated that the recorded O2 saturations were taken while Patient 10 was at rest and with no exertion. The DPCS stated that a comparison of O2 saturation readings while Patient 10 is at rest and during activity should be taken by the nurses, only if it is possible. The DPCS stated that as part of an assessment comparing the O2 sat readings while at rest and during exertion will determine if Patient 10 is progressing or getting worse. During an interview on 10/25/2024, at 12:15 p.m., with Patient 10s Caregiver (CG1), CG1 stated that Patient 10 does not use oxygen therapy daily and uses only if she needed it. CG1 stated that Patient 10 gets easily tired and can have a shortness of breath even when walking for short distances. The CG1 stated when the HA nurses came to visit Patient 10, they will only check the O2 sat while sitting. C. During a review of Patient 11s untitled admission sheet, it indicated a start of care date of 10/4/2024 with a primary diagnosis of chronic obstructive pulmonary disease (a common lung disease causing restricted airflow and breathing problems). During a review of Patient 11's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form, dated 10/11/2024, indicated the frequency of the skilled nurse (SN) visit to one visit per week, the spiritual counselor (SC) and social worker (MSW) to visit one time then prn (pro re nata, as needed). The Hospice aide and volunteer services were declined. During a concurrent interview and record review on 10/25/2024 at 1148 a.m., with the Director of Patient Care Services (DPCS), Patient 11s ";LCD (Local Coverage Determination, is a decision made by a Medicare Administrative Contractor (MAC) on whether a particular service or item is reasonable and necessary, and therefore covered by Medicare within the specific jurisdiction that the MAC oversees) Hospice Eligibility Determination," dated 10/4/2024 was reviewed. The LCD indicated, in documented section 2. Hypoxia (low levels of oxygen in your body tissues ) under b. O2 (Oxygen) saturation (a measurement of how much oxygen in blood is carrying as a percentage of the maximum it could carry) less than or equal to 88% determined either by arterial blood gases (measures the balance of oxygen and carbon dioxide in the blood to see how well lungs are working) or O2 saturation monitors? was marked as ";Yes." The DPCS stated that Patient 11s previous hospital records will support this LCDs questionnaire. During a concurrent review with the DPCS, Patient 11s previous hospital records dated 8/30/2024 indicated Patient 11 ";presents with COPD, she is complaining of SOB (Shortness of Breath) with exertion" but there was no recorded O2 saturation level. The DPCS confirmed and stated that based on the information from Patient 11s previous hospital records, it does not support nor reflect if Patient 10 had O2 saturation of 88% or less because there was no baseline O2 saturation reading. The DPCS stated that the section b. questionnaire from the LCD should have not marked ";Yes", and hospital records should have been reviewed first by the clinicians to support it. The DPCS stated that the LCD was supposed to be completed by the medical doctor with assistance provided by the nurses. During a concurrent review with the DPCS of the following: A. Patient 11s ";Comprehensive Assessment," dated 10/4/2024, indicated documentation of an O2 Sat of 96% on RA (Room Air). B. Patient 11s ";Visit Note LVN (Licensed Vocational Nurse)," dated 10/11/2024 - indicated documentation of an O2 Sat of 97% on RA 10/16/2024 and 10/18/2024 - indicated documentation of an O2 Sat of 98% RA. The DPCS confirmed that Patient 11s O2 saturation were greater than (>) 88%. The DPCS stated that the recorded O2 sats were taken while Patient 11 was at rest and with no exertion. The DPCS stated that a comparison of the O2 saturation readings while Patient 11 was at rest and during activity should be taken by the nurses, only if it is possible. The DPCS stated that as part of the assessment comparing the O2 sat readings during at rest and while exertion will determine if Patient 11 is progressing or getting worse. During an interview on 10/25/2024, at 12:30 p.m., with the Medical Director (MD), the MD stated that for patients with COPD and lung problems that admitted to hospice care, patients usually maxed out their treatments, inhalers, and steroids with little improvements. MD stated that before patients are admitted to hospice care, he reviews their previous clinical records with the assistance of the nurses which includes previous diagnostics (a test used to help figure out what disease or condition a person has based on the signs and symptoms) and laboratory (a medical procedure that involves testing a sample of blood, urine, or other substance from the body) tests and the patients have to present clinical decline. The MD stated for patients with COPD and lung problems, he will expect an O2 saturation usually at 90% or below and if the O2 saturation will significantly drop during activity or even mild exertion. The MD stated that patients O2 saturation could be at 95% when static but with dynamic or when during exertion, it will drop. The MD stated that the nurses should be checking the patients O2 saturation at rest and with exertion as part of their assessment and to determine if the patients health condition is improving and if the patient can continue to be eligible for hospice services. During a review of the agencys policy and procedure (P&P) titled ";Initial Assessment", dated November 2022, the procedure indicated that 1. Admitting registered nurse uses an assessment scale/rating tool to assess for problems and to establish a baseline status of each symptom rated. Items assessed may include, but are not limited to, the following: H. MAC Evaluation. During a review of the agencys policy and procedure (P&P) titled ";Comprehensive Assessment", dated November 2022, the procedure indicated that 4. The Clinical Supervisor will be responsible for assuring that the documentation of clinical findings supports the terminal diagnosis.

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients) failed to conduct an updated comprehensive assessment for one of fourteen sampled patients (Patient 1) related to the deep tissue injury (a form of pressure-induced damage to underlying tissues, including muscles, bones, and subcutaneous layers, while the skin surface might remain intact) on the patients right heel. This deficient practice resulted in Patient 1s skin problem being unmonitored and necessary treatment delayed. --- During a review of Patient 1s Personal Information, the Personal Information indicated Patient 1 was admitted to the HA on 10/12/2023 with a primary diagnosis of Alzheimers disease (a progressive, irreversible brain disorder that destroys nerve cells and damages the brain, which causes a gradual decline in memory, thinking, and behavior). During a review of Patient 1s Re-Cert Assessment, dated 9/25/2024, the Re-Cert Assessment indicated that Patient 1's skin was normal with fair skin turgor (a measure of the skin's elasticity, or its ability to change shape and return to normal). The Re-Cert Assessment indicated that Patient 1 had no wound or skin impairment. During a joint home visit to Patient 1s residence with Licensed Vocational Nurse 1 (LVN 1) on 10/23/2024 at 11 a.m., Patient 1 was observed lying in bed, awake and alert. LVN 1 stated he had never seen Patient 1 before. Patient 1s son (FM 1), who acted as her primary caregiver, was observing the visit through video on a cellular phone. Patient 1s daughter and granddaughter (FM 2) were present at the residence during the home visit. During the home visit, LVN 1 conducted a skin assessment on Patient 1. Patient 1 had a gauze (a type of dry dressing) covering Patient 1s right heel, secured by tape. LVN 1 removed the tape and gauze. Patient 1 had a maroon-purplish colored area on the right heel. The skin on Patient 1s right heel was observed intact. During an interview with FM 1 on 10/23/2024 at 11:55 a.m., FM 1 stated that Patient 1 had the maroon-purplish discoloration on her right heel for a few weeks. FM 1 stated there was a wound specialist that came and saw Patient 1 about two weeks ago. The FM 1 stated the wound specialist examined Patient 1s right heel. According to FM 1, there was no treatment to be done on the maroon-purplish area other than monitoring it. FM 1 stated, ";It looks a lot worse than it did two weeks ago." FM 1 stated the wound specialist was sent by the HA. FM 1 stated that Patient 1 was usually seen by LVN 2. During an interview with FM 2 on 10/23/2024 at 12:10 p.m., FM 2 stated she noted that morning the maroon-purplish discoloration appeared worse. FM 2 stated, ";It looks bigger than before." FM 2 stated she had been monitoring the discoloration on the right heel, as instructed by the wound specialist. On 10/23/24 at _____LVN 1 was observed to apply A & D ointment (a moisturizer that contains vitamin A and D to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations) on the discolored area on the right heel, covered it with dry dressing, and secured it with tape. During a phone interview with LVN 2 on 10/23/2024 at 3:32 p.m., LVN 2 stated she had been the visiting nurse for Patient 1 since admission. LVN 2 stated she saw Patient 1 once a week. Per LVN 2, she noted the maroon-purplish discoloration on Patient 1s right heel on 9/30/2024, which she reported to the HA. LVN 2 stated, the HA then ordered a wound consult for Patient 1. Per LVN 2, there was no treatment order from the wound specialist, except to monitor. LVN 2 stated she completed a skin assessment on 9/30/2024 and took a picture of the discoloration. During a review of Patient 1s Progress Note for the wound specialist visit, dated 10/4/2024, the Progress Note indicated a deep tissue pressure injury on the right heel. The Progress Note indicated the following treatment was ordered for Patient 1 to cleanse with NS (normal saline, a mixture of sodium chloride and water that has a number of uses in medicine including cleaning wounds), pat dry, then apply Betadine (a topical antiseptic that treats minor wounds and prevents skin infections) directly on the wound, cover with gauze and tape. Change dressing once every two days or as needed for loss of integrity or soiling. During a review of Patient 1s Visit Note RN, dated 10/9/2024, the Visit Note RN indicated Patient 1 did not have any wounds, ulcer, or bed sores. The narrative section indicated a supervisory visit and head-to-toe assessment were completed during that visit. The narrative section indicated there was an order for bordered gauze and heel protectors on 10/7/2024 from the wound specialist. During a concurrent interview and record review, with the Director of Patient Care Services (DPCS) on 10/24/2024 at 12:20 p.m., the DPCS stated an updated comprehensive assessment was done during recertification or if the patient had a change of condition. The DPCS reviewed the Visit Note RN, dated 10/9/2024. The DPCS stated the Visit Note RN was not considered an updated comprehensive assessment. The DPCS confirmed there was no updated comprehensive assessment for Patient 1 after the deep tissue pressure injury was observed by LVN 2 on 9/30/2024. Per DPCS, an updated comprehensive assessment that included the change in Patient 1s skin condition should have been completed, so the agency staff could monitor the progress of the wound. During a review of the HAs policy and procedure, titled ";Ongoing Comprehensive Assessments," revised November 2022, the policy and procedure indicated the following: - The nurse will assess the patient on each visit for skin integrity. - Based on the assessments, the plan of care – including problems, needs, goals, and outcomes will be reviewed and updated by the interdisciplinary group members responsible for the case.

Based on observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid 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 HA failed to ensure that the interdisciplinary group maintained responsibility for directing, coordinating, and supervising the care and services provided for one of fourteen sampled patients (Patient 1). (Refer to L539). This deficient practice resulted in Patient 1 not receiving the wound treatment ordered by the physician from 10/7/2024 to 10/23/2024. 2. The HA failed to provide the supplies and treatment necessary for one of fourteen sampled patients (Patient 1) related to the wound care. (Refer to L549). This deficient practice resulted in Patient 1s wound progress being unmonitored and potentially delayed. 3. The HA failed to develop an individualized plan of care that included integumentary problems and interventions for one of fourteen sampled patients (Patient 1). (Refer to L545). This deficient practice resulted in Patient 1s problem not being addressed, and interventions not being done and potentially preventing patient goals achieved. 4. The HA failed to review and revise the plan of care (POC, a document that maps out needs and services supplied for a Medicare patient facing a terminal illness, as well as the patient's family/caregiver) as the patients condition required for one of fourteen sampled patients (Patient 1). (Refer to L552). This deficient practice resulted in Patient 1s problem not being addressed, and interventions not being done and potentially preventing patient goals achieved. 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.

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure that the interdisciplinary group maintained responsibility for directing, coordinating, and supervising the care and services provided for one of fourteen sampled patients (Patient 1). This deficient practice resulted in Patient 1 not receiving the wound treatment that was ordered by the physician on 10/4/2024. --- During a review of Patient 1s Personal Information, the Personal Information indicated that Patient 1 was admitted to the HA on 10/12/2023, with a primary diagnosis of Alzheimers disease (a progressive, irreversible brain disorder that destroys nerve cells and damages the brain, which causes a gradual decline in memory, thinking, and behavior). During a joint home visit to Patient 1s residence with Licensed Vocational Nurse 1 (LVN 1) on 10/23/2024 at 11 a.m., Patient 1 was observed lying in bed, awake and alert. LVN 1 stated he had never seen Patient 1 before. Patient 1s son (FM 1), who acted as her primary caregiver, was observing the visit through video on a cellular phone. Patient 1s daughter and granddaughter (FM 2) were present at the residence during the home visit. During the home visit, LVN 1 conducted a skin assessment on Patient 1. Patient 1 had a gauze (a type of dry dressing) covering Patient 1s right heel, which was secured by tape. LVN 1 removed the tape and gauze. Patient 1 had a maroon-purplish colored area on the right heel. The skin on Patient 1s right heel was intact. During an interview with FM 1 on 10/23/2024 at 11:55 a.m., FM 1 stated that Patient 1 had had the maroon-purplish discoloration on her right heel for a few weeks. FM 1 stated there was a wound specialist that came and saw Patient 1 about two weeks ago. FM 1 stated the wound specialist examined Patient 1s right heel. According to FM 1, there was no treatment to be done on the maroon-purplish area other than monitoring it. FM 1 stated, ";It looks a lot worse than it did two weeks ago." FM 1 stated the wound specialist was sent by the HA. FM 1 stated that Patient 1 was usually seen by LVN 2. During a phone interview with LVN 2 on 10/23/2024 at 3:32 p.m., LVN 2 stated she had been the visiting nurse for Patient 1 since admission. LVN 2 stated she saw Patient 1 once a week. Per LVN 2, she noted the maroon-purplish discoloration on Patient 1s right heel on 9/30/2024, which she reported to the HA. LVN 2 stated, the HA then ordered a wound consult for Patient 1. Per LVN 2, there was no treatment order from the wound specialist, except to monitor. LVN 2 stated she completed a skin assessment on 9/30/2024 and took a picture of the discoloration. During a review of Patient 1s Visit Note LVN, dated 10/14/2024 and Visit Note RN, dated 10/9/2024, both notes indicated that Patient 1 did not have any wounds, ulcer, or bed sores. Both notes did not mention any wound treatment being performed during the visits. During a review of Patient 1s Progress Note for the wound specialist visit, dated 10/4/2024, the Progress Note indicated a deep tissue pressure injury on the right heel. The Progress Note indicated the following treatment was ordered for Patient 1: Cleanse with NS (normal saline, a mixture of sodium chloride and water that has a number of uses in medicine including cleaning wounds), pat dry, then apply Betadine (a topical antiseptic that treats minor wounds and prevents skin infections) directly on the wound, cover with gauze and tape. Change dressing once every two days or as needed for loss of integrity or soiling. During a review of Patient 1s Plan of Care/Interdisciplinary Group Review (POC/IDG Review, a review of the patients plan of care by team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), dated 10/11/2024, the POC/IDG Review did not include Patient 1s integumentary (skin) problem and intervention as identified in the Progress Note dated 10/4/2024. The POC/IDG Review was signed by the HAs Medical Director (MD), Director of Patient Care Services (DPCS), Master of Social Work (MSW), and Spiritual Counselor (SC). During an interview with the DPCS on 10/24/2024 at 2:30 p.m., the DPCS stated he was aware of the wound treatment ordered by the wound specialist on 10/4/2024. The DPCS stated that somehow the order was not communicated among the IDG members, and therefore the HA did not obtain the wound treatment order from its Medical Director, and thus it was not carried out. The DPCS stated that all physician orders had to be included in the POC/IDG Review, so that all staff would be aware. During a review of the HAs policy and procedure, titled ";Interdisciplinary Group Coordination of Care," revised November 2022, the policy and procedure indicated that the interdisciplinary group would conduct assessments, develop, and update the plan of care, and review the effectiveness of care a minimum of every two weeks. The policy and procedure also indicated the interdisciplinary group shall direct, coordinate, and supervise the hospice services.

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to include all services necessary for the palliation and management of the terminal illness and related conditions for one of fourteen sampled patients (Patient 1). This deficient practice resulted in Patient 1s wound treatment order not being carried out and wound healing potentially delayed. --- During a review of Patient 1s Personal Information, the Personal Information indicated that Patient 1 was admitted to the HA on 10/12/2023 with a primary diagnosis of Alzheimers disease (a progressive, irreversible brain disorder that destroys nerve cells and damages the brain, which causes a gradual decline in memory, thinking, and behavior). During a review of Patient 1s Progress Note for the wound specialist visit, dated 10/4/2024, the Progress Note indicated a deep tissue pressure injury on the right heel, measuring 2.0 cm (a measurement unit) in length, 2.3 cm in width, and 0.1 cm in depth. The Progress Note indicated the following treatment was ordered for Patient 1: Cleanse with NS (normal saline, a mixture of sodium chloride and water that has a number of uses in medicine including cleaning wounds), pat dry, then apply Betadine (a topical antiseptic that treats minor wounds and prevents skin infections) directly on the wound, cover with gauze and tape. Change dressing once every two days or as needed for loss of integrity or soiling. During a review of Patient 1s Visit Note RN, dated 10/9/2024, the Visit Note RN indicated Patient 1 did not have any wounds, ulcer, or bed sores. The narrative section indicated a supervisory visit and head-to-toe assessment were completed during that visit. The narrative section indicated there was an order for bordered gauze and heel protectors on 10/7/2024 from the wound specialist. There was no documentation that wound treatment was provided. During a review of Patient 1s Plan of Care/Interdisciplinary Group Review (POC/IDG Review, a review of the patients plan of care by team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), dated 10/11/2024, the POC/IDG Review did not include Patient 1s integumentary (skin) problem and intervention as identified in the Progress Note dated 10/4/2024. The POC/IDG Review was signed by the HAs Medical Director (MD), Director of Patient Care Services (DPCS), Master of Social Work (MSW), and Spiritual Counselor (SC). During a review of Patient 1s Visit Note LVN, dated 10/14/2024, the Visit Note LVN indicated Patient 1 did not have any wounds, ulcer, or bed sores. The narrative section indicated the skin was warm and dry; skin was intact with no impairments. There was no documentation that wound treatment was provided. During a joint home visit to Patient 1s residence with Licensed Vocational Nurse 1 (LVN 1) on 10/23/2024 at 11 a.m., Patient 1 was observed lying in bed, awake and alert. LVN 1 stated he had never seen Patient 1 before. Patient 1s son (FM 1), who acted as her primary caregiver, was observing the visit through video on a cellular phone. Patient 1s daughter and granddaughter (FM 2) were present at the residence during the home visit. During the home visit, on 10/23/24, LVN 1 conducted a skin assessment on Patient 1. Patient 1 had a gauze (a type of dry dressing) covering Patient 1s right heel, which was secured by tape. LVN 1 removed the tape and gauze. Patient 1 had a maroon-purplish colored area on the right heel. The skin on Patient 1s right heel was intact. LVN 1 applied A & D ointment (a moisturizer that contains vitamin A and D to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations) on the discolored area on the right heel, covered it with dry dressing, and secured it with tape. During an interview with FM 1 on 10/23/2024 at 11:55 a.m., FM 1 stated that Patient 1 had had the maroon-purplish discoloration on her right heel for a few weeks. FM 1 stated there was a wound specialist that came and saw Patient 1 about two weeks ago. FM 1 stated the wound specialist examined Patient 1s right heel. According to FM 1, there was no treatment to be done on the maroon-purplish area other than monitoring it. FM 1 stated, ";It looks a lot worse than it did two weeks ago." FM 1 stated the wound specialist was sent by the HA. FM 1 stated that Patient 1 was usually seen by LVN 2. During an interview with FM 2 on 10/23/2024 at 12:10 p.m., FM 2 stated she noted that morning the maroon-purplish discoloration appeared worse. FM 2 stated, ";It looks bigger than before." FM 2 stated she had been monitoring the discoloration on the right heel, as instructed by the wound specialist. During a phone interview with LVN 2 on 10/23/2024 at 3:32 p.m., LVN 2 stated she had been the visiting nurse for Patient 1 since admission. LVN 2 stated she saw Patient 1 once a week. Per LVN 2, she noted the maroon-purplish discoloration on Patient 1s right heel on 9/30/2024, which she reported to the HA. LVN 2 stated, the HA then ordered a wound consult for Patient 1. Per LVN 2, there was no treatment order from the wound specialist, except to monitor. LVN 2 stated she completed a skin assessment on 9/30/2024 and took a picture of the discoloration. There was no measurement documented. During a phone interview with LVN 2 on 10/24/2024 at 12:25 p.m., LVN 2 stated she was not aware there was a wound treatment ordered by the wound specialist. LVN 2 stated, ";As far as I know, theres no treatment. Its just monitoring for now." During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 10/24/2024 at 12:50 p.m., the DPCS reviewed the Visit Note RN, dated 10/9/2024, and the Visit Note LVN, dated 10/14/2024. The DPCS confirmed there was no wound treatment provided based on the documentation. During an interview with the DPCS on 10/24/2024 at 2:30 p.m., the DPCS stated he was aware of the wound treatment ordered by the wound specialist on 10/4/2024. The DPCS stated that somehow the order was not communicated among the IDG members, and therefore the HA did not obtain the wound treatment order from its Medical Director, and thus it was not carried out. The DPCS stated that all physician orders must be included in the patients plan of care. During a review of the HAs policy and procedure, titled ";The Plan of Care," revised November 2022, the policy and procedure indicated the written plan of care will contain, but will not be limited to, the following: S. Physician (or other authorized licensed independent practitioner) orders. The policy and procedure also indicated that care provided to the patient will be in accordance with the plan of care.

Based on observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to provide the supplies and treatment necessary for one of fourteen sampled patients (Patient 1) related to wound care. This deficient practice resulted in Patient 1s wound progress being unmonitored and potentially delayed. --- During a review of Patient 1s Personal Information, the Personal Information indicated that Patient 1 was admitted to the HA on 10/12/2023 with a primary diagnosis of Alzheimers disease (a progressive, irreversible brain disorder that destroys nerve cells and damages the brain, which causes a gradual decline in memory, thinking, and behavior). During a review of Patient 1s Progress Note for the wound specialist visit, dated 10/4/2024, the Progress Note indicated a deep tissue pressure injury on the right heel, measuring 2.0 cm (a measurement unit) in length, 2.3 cm in width, and 0.1 cm in depth. The Progress Note indicated the following treatment was ordered for Patient 1: Cleanse with NS (normal saline, a mixture of sodium chloride and water that has a number of uses in medicine including cleaning wounds), pat dry, then apply Betadine (a topical antiseptic that treats minor wounds and prevents skin infections) directly on the wound, cover with gauze and tape. Change dressing once every two days or as needed for loss of integrity or soiling. During a review of Patient 1s Current Treatment/Medication/DME (Durable Medical Equipment, medically necessary items designed for long-term use at home) List, the Current Treatment/Medication/DME List did not include the normal saline, Betadine, or the wound care treatment ordered for Patient 1. During a review of Patient 1s Visit Note RN, dated 10/9/2024, the Visit Note RN indicated Patient 1 did not have any wounds, ulcer, or bed sores. The narrative section indicated a supervisory visit and head-to-toe assessment were completed during that visit. The narrative section indicated there was an order for bordered gauze and heel protectors on 10/7/2024 from the wound specialist. There was no documentation that wound treatment was provided. During a review of Patient 1s Visit Note LVN, dated 10/14/2024, the Visit Note LVN indicated Patient 1 did not have any wounds, ulcer, or bed sores. The narrative section indicated the skin was warm and dry; skin was intact with no impairments. There was no documentation that wound treatment was provided. During a joint home visit to Patient 1s residence with Licensed Vocational Nurse 1 (LVN 1) on 10/23/2024 at 11 a.m., observed Patient 1 lying in bed, awake and alert. LVN 1 stated he had never seen Patient 1 before. Patient 1s son (FM 1), who acted as her primary caregiver, was observing the visit through video on a cellular phone. Patient 1s daughter (FM 3) and granddaughter (FM 2) were present at the residence during the home visit. During the home visit, LVN 1 conducted skin assessment on Patient 1. Observed a gauze (a type of dry dressing) covering Patient 1s right heel, secured by tape. Observed LVN 1 remove the tape and gauze. Observed maroon-purplish colored area on Patient 1s right heel. The skin on Patient 1s right heel was intact. During an interview with FM 1 on 10/23/2024 at 11:55 a.m., FM 1 stated that Patient 1 had had the maroon-purplish discoloration on her right heel for a few weeks. FM 1 stated there was a wound specialist that came and see Patient 1 about two weeks ago. FM 1 stated the wound specialist examined Patient 1s right heel. According to FM 1, there was no treatment to be done on the maroon-purplish area other than monitoring it. FM 1 stated, ";It looks a lot worse than it did two weeks ago." FM 1 stated the wound specialist was sent by the HA. FM 1 stated that Patient 1 was usually seen by LVN 2. During an interview with FM 3 on 10/23/2024 at 12:05 p.m., FM 3 stated that she and FM 2 live with Patient 1, and FM 2 checked Patient 1s skin every day. During an interview with FM 2 on 10/23/2024 at 12:10 p.m., FM 2 stated she noted that morning the maroon-purplish discoloration appeared worse. FM 2 stated, ";It looks bigger than before." FM 2 stated she had been monitoring the discoloration on the right heel, as instructed by the wound specialist. During a phone interview with LVN 2 on 10/23/2024 at 3:32 p.m., LVN 2 stated she had been the visiting nurse for Patient 1 since admission. LVN 2 stated she saw Patient 1 once a week. Per LVN 2, she noted the maroon-purplish discoloration on Patient 1s right heel on 9/30/2024, which she reported to the HA. LVN 2 stated, the HA then ordered a wound consult for Patient 1. Per LVN 2, there was no treatment order from the wound specialist, except to monitor. LVN 2 stated she completed a skin assessment on 9/30/2024 and took a picture of the discoloration. There was no measurement documented. During a phone interview with LVN 2 on 10/24/2024 at 12:25 p.m., LVN 2 stated she was not aware there was a wound treatment ordered by the wound specialist. LVN 2 stated, ";As far as I know, theres no treatment. Its just monitoring for now." During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 10/24/2024 at 12:50 p.m., the DPCS reviewed the Visit Note RN, dated 10/9/2024, and the Visit Note LVN, dated 10/14/2024. The DPCS confirmed there was no wound treatment provided based on the documentation. During an interview with the DPCS on 10/24/2024 at 2:50 p.m., when the surveyor showed the DPCS a picture of the wound taken during the home visit, the DPCS stated the wound appeared worse. The DPCS confirmed there was no measurement taken of the wound by the HA staff. The DPCS stated that he would send LVN 1 later that afternoon to see Patient 1 and perform the wound care. During a review of the HAs undated, policy and procedure, titled ";Wound Assessment and Documentation," the policy and procedure indicated that wound measurement was to be taken every two weeks, including the length, depth, and width in centimeters. During a review of the HAs policy and procedure, titled ";The Plan of Care," revised November 2022, the policy and procedure indicated the plan of care would identify the patients needs and services to meet those needs, including the management of pain and discomfort and symptom relief.

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to review and revise the individualized plan of care for one of fourteen sampled patients (Patient 1) as the patients condition required. This deficient practice resulted in Patient 1s wound treatment order not carried out and wound healing potentially delayed. --- During a review of Patient 1s Personal Information, the Personal Information indicated that Patient 1 was admitted to the HA on 10/12/2023 with a primary diagnosis of Alzheimers disease (a progressive, irreversible brain disorder that destroys nerve cells and damages the brain, which causes a gradual decline in memory, thinking, and behavior). During a review of Patient 1s Progress Note for the wound specialist visit, dated 10/4/2024, the Progress Note indicated a deep tissue pressure injury on the right heel, measuring 2.0 cm (a measurement unit) in length, 2.3 cm in width, and 0.1 cm in depth. The Progress Note indicated the following treatment was ordered for Patient 1: Cleanse with NS (normal saline, a mixture of sodium chloride and water that has a number of uses in medicine including cleaning wounds), pat dry, then apply Betadine (a topical antiseptic that treats minor wounds and prevents skin infections) directly on the wound, cover with gauze and tape. Change dressing once every two days or as needed for loss of integrity or soiling. During a review of Patient 1s Visit Note RN, dated 10/9/2024, the Visit Note RN indicated Patient 1 did not have any wounds, ulcer, or bed sores. The narrative section indicated a supervisory visit and head-to-toe assessment were completed during that visit. The narrative section indicated there was an order for bordered gauze and heel protectors on 10/7/2024 from the wound specialist. There was no documentation that wound treatment was provided. During a review of Patient 1s Plan of Care/Interdisciplinary Group Review (POC/IDG Review, a review of the patients plan of care by team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), dated 10/11/2024, the POC/IDG Review did not include Patient 1s integumentary (skin) problem and intervention as identified in the Progress Note dated 10/4/2024. The POC/IDG Review was signed by the HAs Medical Director (MD), Director of Patient Care Services (DPCS), Master of Social Work (MSW), and Spiritual Counselor (SC). During a review of Patient 1s Visit Note LVN, dated 10/14/2024, the Visit Note LVN indicated Patient 1 did not have any wounds, ulcer, or bed sores. The narrative section indicated the skin was warm and dry; skin was intact with no impairments. There was no documentation that wound treatment was provided. During a joint home visit to Patient 1s residence with Licensed Vocational Nurse 1 (LVN 1) on 10/23/2024 at 11 a.m., Patient 1 was observed lying in bed, awake and alert. LVN 1 stated he had never seen Patient 1 before. Patient 1s son (FM 1), who acted as her primary caregiver, was observing the visit through video on a cellular phone. Patient 1s daughter and granddaughter (FM 2) were present at the residence during the home visit. During the home visit, LVN 1 conducted a skin assessment on Patient 1. Patient 1 had a gauze (a type of dry dressing) covering on the right heel, secured by tape. LVN 1 removed the tape and gauze. Patient 1 was observed to have a maroon-purplish colored area on the right heel. The skin on Patient 1s right heel was observed intact. LVN 1 applied A & D ointment (a moisturizer that contains vitamin A and D to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations) on the discolored area on the right heel, covered it with dry dressing, and secured it with tape. During an interview with FM 1 on 10/23/2024 at 11:55 a.m., FM 1 stated that Patient 1 had had the maroon-purplish discoloration on her right heel for a few weeks. FM 1 stated there was a wound specialist that came and see Patient 1 about two weeks ago. FM 1 stated the wound specialist examined Patient 1s right heel. According to FM 1, there was no treatment to be done on the maroon-purplish area other than monitoring it. FM 1 stated, ";It looks a lot worse than it did two weeks ago." FM 1 stated the wound specialist was sent by the HA. FM 1 stated that Patient 1 was usually seen by LVN 2. During an interview with FM 2 on 10/23/2024 at 12:10 p.m., FM 2 stated she noted that morning the maroon-purplish discoloration appeared worse. FM 2 stated, ";It looks bigger than before." FM 2 stated she had been monitoring the discoloration on the right heel, as instructed by the wound specialist. During a phone interview with LVN 2 on 10/23/2024 at 3:32 p.m., LVN 2 stated she had been the visiting nurse for Patient 1 since admission. LVN 2 stated she saw Patient 1 once a week. Per LVN 2, she noted the maroon-purplish discoloration on Patient 1s right heel on 9/30/2024, which she reported to the HA. LVN 2 stated, the HA then ordered a wound consult for Patient 1. Per LVN 2, there was no treatment order from the wound specialist, except to monitor. LVN 2 stated she completed a skin assessment on 9/30/2024 and took a picture of the discoloration. There was no measurement documented. During a phone interview with LVN 2 on 10/24/2024 at 12:25 p.m., LVN 2 stated she was not aware there was a wound treatment ordered by the wound specialist. LVN 2 stated, ";As far as I know, theres no treatment. Its just monitoring for now." During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 10/24/2024 at 12:50 p.m., the DPCS reviewed the Visit Note RN, dated 10/9/2024, and the Visit Note LVN, dated 10/14/2024. The DPCS confirmed there was no wound treatment provided based on the documentation. During an interview with the DPCS on 10/24/2024 at 2:30 p.m., the DPCS stated he was aware of the wound treatment ordered by the wound specialist on 10/4/2024. The DPCS stated that Patient 1s plan of care should have been revised to include the deep tissue injury on the right heel and the wound care ordered by the wound specialist on 10/4/2024. During a review of the HAs policy and procedure, titled ";The Plan of Care," revised November 2022, the policy and procedure indicated the plan of care would be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, by the interdisciplinary group, with input from the attending physician, the patient, and the family/caregiver, based on ongoing comprehensive assessment of the patient and family/caregiver.

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation for Clinical Records was met as follows: 1 --- 1. The HA failed to include an updated comprehensive assessment, updated plan of care, and updated clinical notes for two of fourteen sampled patients (Patient 1 and Patient 9). (Refer to L672). This deficient practice resulted in Patient 1 and Patient 9 having incomplete clinical records that could potentially result in not identifying a change in each patients conditions and affect the care and services received by the patients. 2 The HA failed to include the physician order related to wound care for one of fourteen sampled patients (Patient 1). (Refer to L678). This deficient practice resulted in the HA staff being unaware of the wound care order, therefore it was not done. 3 The HA failed to include the plan of care, most recent physician orders, and any other documentations that will assist in post-discharge continuity of care for one of fourteen sampled patients (Patient 7). (Refer to L684). This deficient practice resulted in Patient 7to not receive the appropriate nursing care or services after being discharged from the hospital. The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Clinical Records to maintain accurate and updated clinical records for all patients. Findings

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to include an updated comprehensive assessment, updated plan of care, and updated clinical notes for two of fourteen sampled patients (Patient 1 and Patient 9). This deficient practice resulted in Patient 1 and Patient 9 to not have completed clinical records that could potentially not identify a change in patients conditions and affect the care and services received by the patients. --- a. During a review of Patient 1s Personal Information, the Personal Information indicated that Patient 1 was admitted to the HA on 10/12/2023 with a primary diagnosis of Alzheimers disease (a progressive, irreversible brain disorder that destroys nerve cells and damages the brain, which causes a gradual decline in memory, thinking, and behavior). During a joint home visit to Patient 1s residence with Licensed Vocational Nurse 1 (LVN 1) on 10/23/2024 at 11 a.m., observed Patient 1 lying in bed, awake and alert. LVN 1 stated he had never seen Patient 1 before. Patient 1s son (FM 1), who acted as her primary caregiver, was observing the visit through video on a cellular phone. Patient 1s daughter and granddaughter (FM 2) were present at the residence during the home visit. During the home visit, LVN 1 conducted skin assessment on Patient 1. Observed a gauze (a type of dry dressing) covering Patient 1s right heel, secured by tape. Observed LVN 1 remove the tape and gauze. Observed maroon-purplish colored area on Patient 1s right heel. The skin on Patient 1s right heel was observed intact. During an interview with FM 1 on 10/23/2024 at 11:55 a.m., FM 1 stated that Patient 1 had had the maroon-purplish discoloration on her right heel for a few weeks. FM 1 stated there was a wound specialist that came and see Patient 1 about two weeks ago. FM 1 stated the wound specialist examined Patient 1s right heel. According to FM 1, there was no treatment to be done on the maroon-purplish area other than monitoring it. FM 1 stated, ";It looks a lot worse than it did two weeks ago." FM 1 stated the wound specialist was sent by the HA. FM 1 stated that Patient 1 was usually seen by LVN 2. During a phone interview with LVN 2 on 10/23/2024 at 3:32 p.m., LVN 2 stated she had been the visiting nurse for Patient 1 since admission. LVN 2 stated she saw Patient 1 once a week. Per LVN 2, she noted the maroon-purplish discoloration on Patient 1s right heel on 9/30/2024, which she reported to the HA. LVN 2 stated, the HA then ordered a wound consult for Patient 1. Per LVN 2, there was no treatment order from the wound specialist, except to monitor. LVN 2 stated she completed a skin assessment on 9/30/2024 and took a picture of the discoloration. There was no measurement documented. During a review of Patient 1s Progress Note for the wound specialist visit, dated 10/4/2024, the Progress Note indicated a deep tissue pressure injury on the right heel, measuring 2.0 cm (a measurement unit) in length, 2.3 cm in width, and 0.1 cm in depth. The Progress Note indicated the following treatment was ordered for Patient 1: Cleanse with NS (normal saline, a mixture of sodium chloride and water that has a number of uses in medicine including cleaning wounds), pat dry, then apply Betadine (a topical antiseptic that treats minor wounds and prevents skin infections) directly on the wound, cover with gauze and tape. Change dressing once every two days or as needed for loss of integrity or soiling. During a review of Patient 1s Visit Note RN, dated 10/9/2024, the Visit Note RN indicated Patient 1 did not have any wounds, ulcer, or bed sores. The narrative section indicated a supervisory visit and head-to-toe assessment were completed during that visit. The narrative section indicated there was an order for bordered gauze and heel protectors on 10/7/2024 from the wound specialist. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 10/24/2024 at 12:20 p.m., the DPCS stated an updated comprehensive assessment was done during recertification or if the patient had a change of condition. The DPCS reviewed the Visit Note RN, dated 10/9/2024. The DPCS stated the Visit Note RN was not considered an updated comprehensive assessment. The DPCS confirmed there was no updated comprehensive assessment for Patient 1 after the deep tissue pressure injury was observed by LVN 2 on 9/30/2024. Per DPCS, an updated comprehensive assessment that included the change in Patient 1s skin condition should have been completed, so the agency staff could monitor the progress of the wound. During a review of Patient 1s Plan of Care/Interdisciplinary Group Review (POC/IDG Review, a review of the patients plan of care by team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), dated 10/11/2024, the POC/IDG Review did not include Patient 1s integumentary (skin) problem and intervention as identified in the Progress Note dated 10/4/2024. The POC/IDG Review was signed by the HAs Medical Director (MD), Director of Patient Care Services (DPCS), Master of Social Work (MSW), and Spiritual Counselor (SC). During an interview with the DPCS on 10/24/2024 at 2:30 p.m., the DPCS stated he was aware of the wound treatment ordered by the wound specialist on 10/4/2024. The DPCS stated that Patient 1s plan of care should have been revised to include the deep tissue injury on the right heel and the wound care ordered by the wound specialist on 10/4/2024. During an interview with the DPCS on 10/25/2024 at 1:50 p.m., the DPCS stated that it was the HAs responsibility to maintain updated and accurate clinical record for each patient, so that all staff could be on the same page regarding patients condition, interventions, and goals. During a review of the HAs policy and procedure, titled ";Contents of the Clinical Record," revised November 2022, the policy and procedure indicated the clinical record would contain sufficient information to identify the patient, describe patient problems/needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contract personnel. B. During a review of Patient 9s untitled admission sheet, it indicated a start of care date on 9/8/2024 with a primary diagnosis of Anorexia (an eating disorder that causes to weigh less than is considered healthy for their age and height, usually by excessive weight loss). During a review of Patient 9's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form, dated 10/11/2024, indicated the frequency of the skilled nurse (SN) to one visit per week, the spiritual counselor (SC) and social worker (MSW) to visit one time then prn (pro re nata, as needed). Hospice aide and volunteer services were declined. During a joint home visit with the Director of Patient Care Services (DPCS) on 10/23/2024 at 11:17 a.m., Patient 9 was observed resting on her bed, awake and confused, Patient 9s daughter (Family Member/FM4) stated that her mother is bed ridden and only responds when name was called. During observation, the DPCS performed hand hygiene, conducted his assessment to Patient 9 and took her vital signs but did not performed MAC measurement or weight check. During a concurrent review with the DPCS of the following: A. Patient 9s ";Current Treatment/Medication/DME (Durable Medical Equipment) List," dated 9/8/2024, indicated an order that ";Skilled Nurse may check MAC as needed." B. Patient 9s ";Comprehensive Nursing Assessment," dated 9/8/2024, indicated no documentation of MAC or weight. C. Patient 9s ";Visit Note LVN (Licensed Vocational Nurse)," dated 9/22/2024, 10/6/2024 and 10/20/2024, indicated no documentation of MAC or weight. DPCS confirmed that there were no documented MAC nor weight for Patient 9. DPCS stated that it is important that a baseline MAC or weight was documented in the comprehensive nursing assessment since it was the initial visit made for Patient 9. DPCS stated that MAC or weight should have been checked and documented by the visiting nurses in order to monitor if Patient 9 is continuously losing weight or improving, DPCS stated that the IDG and health care team involved in Patient 9s care will not be able to determine if any weight changed occurred if no MAC or weight documented. During a review of the agencys policy and procedure (P&P) titled ";Initial Assessment", dated November 2022, the procedure indicated that 1. Admitting registered nurse uses an assessment scale/rating tool to assess for problems and to establish a baseline status of each symptom rated. Items assessed may include, but are not limited to, the following: H. MAC Evaluation.

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to include physician order related to wound care as part of the patient's clinical record for one of fourteen sampled patients (Patient 1). This deficient practice resulted in the IDG members unaware of the wound care order, therefore it was not done, and the patients wound was unmonitored. --- During a review of Patient 1s Personal Information, the Personal Information indicated that Patient 1 was admitted to the HA on 10/12/2023 with a primary diagnosis of Alzheimers disease (a progressive, irreversible brain disorder that destroys nerve cells and damages the brain, which causes a gradual decline in memory, thinking, and behavior). During a review of Patient 1s Progress Note for the wound specialist visit, dated 10/4/2024, the Progress Note indicated a deep tissue pressure injury on the right heel, measuring 2.0 cm (a measurement unit) in length, 2.3 cm in width, and 0.1 cm in depth. The Progress Note indicated the following treatment was ordered for Patient 1: Cleanse with NS (normal saline, a mixture of sodium chloride and water that has a number of uses in medicine including cleaning wounds), pat dry, then apply Betadine (a topical antiseptic that treats minor wounds and prevents skin infections) directly on the wound, cover with gauze and tape. Change dressing once every two days or as needed for loss of integrity or soiling. During a review of Patient 1s Current Treatment/Medication/DME (Durable Medical Equipment, medically necessary items designed for long-term use at home) List, the Current Treatment/Medication/DME List did not include the normal saline, Betadine, or the wound care treatment ordered for Patient 1. During a review of Patient 1s Visit Note RN, dated 10/9/2024, the Visit Note RN indicated Patient 1 did not have any wounds, ulcer, or bed sores. The narrative section indicated a supervisory visit and head-to-toe assessment were completed during that visit. The narrative section indicated there was an order for bordered gauze and heel protectors on 10/7/2024 from the wound specialist. There was no documentation that wound treatment was provided. During a review of Patient 1s Visit Note LVN, dated 10/14/2024, the Visit Note LVN indicated Patient 1 did not have any wounds, ulcer, or bed sores. The narrative section indicated the skin was warm and dry; skin was intact with no impairments. There was no documentation that wound treatment was provided. During a joint home visit to Patient 1s residence with Licensed Vocational Nurse 1 (LVN 1) on 10/23/2024 at 11 a.m., Patient 1 was observed lying in bed, awake and alert. LVN 1 stated he had never seen Patient 1 before. Patient 1s son (FM 1), who acted as her primary caregiver, was observing the visit through video on a cellular phone. Patient 1s daughter and granddaughter (FM 2) were present at the residence during the home visit. During the home visit, LVN 1 conducted a skin assessment on Patient 1. Patient 1 had a gauze (a type of dry dressing) covering Patient 1s right heel, secured by tape. LVN 1 removed the tape and gauze. Patient 1 had a maroon-purplish colored area on Patient 1s right heel. The skin on Patient 1s right heel was observed intact. During an interview with FM 1 on 10/23/2024 at 11:55 a.m., FM 1 stated that Patient 1 had had the maroon-purplish discoloration on her right heel for a few weeks. FM 1 stated there was a wound specialist that came and see Patient 1 about two weeks ago. FM 1 stated the wound specialist examined Patient 1s right heel. According to FM 1, there was no treatment to be done on the maroon-purplish area other than monitoring it. FM 1 stated, ";It looks a lot worse than it did two weeks ago." FM 1 stated the wound specialist was sent by the HA. FM 1 stated that Patient 1 was usually seen by LVN 2. During a phone interview with LVN 2 on 10/23/2024 at 3:32 p.m., LVN 2 stated she had been the visiting nurse for Patient 1 since admission. LVN 2 stated she saw Patient 1 once a week. Per LVN 2, she noted the maroon-purplish discoloration on Patient 1s right heel on 9/30/2024, which she reported to the HA. LVN 2 stated, the HA then ordered a wound consult for Patient 1. Per LVN 2, there was no treatment order from the wound specialist, except to monitor. LVN 2 stated she completed a skin assessment on 9/30/2024 and took a picture of the discoloration. There was no measurement documented. During a phone interview with LVN 2 on 10/24/2024 at 12:25 p.m., LVN 2 stated she was not aware there was a wound treatment ordered by the wound specialist. LVN 2 stated, ";As far as I know, theres no treatment. Its just monitoring for now." During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 10/24/2024 at 12:50 p.m., the DPCS reviewed the Visit Note RN, dated 10/9/2024, and the Visit Note LVN, dated 10/14/2024. The DPCS confirmed there was no wound treatment provided based on the documentation. During an interview with the DPCS on 10/25/2024 at 2 p.m., the DPCS stated all physician orders, whether it was from the HAs physician or other authorized licensed independent practitioner must be listed in the patients Current Treatment/Medication/DME List. According to the DPCS, all medications and wound supplies, such as normal saline and Betadine, also needed to be listed. Per DPCS, the purpose of including physician orders and current treatment in the patients clinical record was to ensure the clinical record reflected patients health status accurately. During a review of the HAs policy and procedure, titled ";Contents of the Clinical Record," revised November 2022, the policy and procedure indicated that legible, complete, and individualized diagnostic and therapeutic orders authenticated within the time frame defined by the organization, or according to law and regulation would be available in the clinical record.

Based on record review and interview, the facility failed to include the patients plan of care, most recent physician orders, and any other documentations that will assist in post-discharge continuity of care for one of fourteen sampled patients (Patient 7). This deficient practice had the potential to result in Patient 7 to not receive the appropriate nursing care or services after being discharged from the hospital. --- During a review of Patient 7s Personal Information, the Personal Information indicated that Patient 7 was admitted to the HA on 11/18/2022 with a primary diagnosis of polyneuropathy (a general degeneration of peripheral nerves that spreads towards the center of the body). The Personal Information indicated that Patient 7 was discharged on 7/20/2024. During a review of Patient 7s POC/IDG Review (Plan of Care/Interdisciplinary Group Review, a review of the patients plan of care by team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), dated 7/19/2024, indicated LVN (Licensed Vocational Nurse, a licensed nurse in general) visit once per week and as needed, and RN (Registered Nurse) visit once every two weeks and as needed. During a review of Patient 7s Physicians Order, dated 7/20/2024, the Physicians Order indicated an order to discharge Patient 7 from the HA due to hospitalization, however Patient 7 was not treated at the hospital until 7/22/2024. During a phone interview with the HAs office manager on 8/27/2024 at 10:40 a.m., the office manager stated the HA discharged Patient 7 on 7/20/2024 due to hospitalization. The office manager admitted that Patient 7 did not go to the hospital until 7/22/2024. The office manager acknowledged that the discharge summary and discharge order with a date of 7/20/2024 was incorrect because Patient 7 did not go to the hospital until 7/22/2024. During an interview with the Director of Patient Care Services (DPCS) on 10/22/2024 at 2:55 p.m., the DPCS stated he remembered receiving a phone call from Patient 7s neighbor, informing him that Patient 7 had a fall and wanted to be taken to the hospital. The DPCS stated he could not remember the exact date he received the phone call. The DPCS stated he had to go by the date on his documentation for Patient 7, titled ";Incident/Occurrence," which listed the date of the fall and the date Patient 7 called paramedic as 7/202024. During a review of Patient 7s Discharge Summary, dated 7/20/2024, the Discharge Summary did not accurately reflect the date Patient 7 was actually seen in the hospital, which was 7/22/2024. The Discharge Summary for Patient 7 did not include the plan of care, most recent physician orders, and/or discharge instruction. A review of the HAs policy and procedure, titled ";Discharge from Hospice Program," revised November 2022, indicated the purpose of the policy was to establish standards and a process by which patients are discharged from the hospice program. Under the section discharge criteria, ";hospitalization" was not listed as a reason for discharge.

Based on observation, interview and record review, the hospice agency (HA) failed to maintain an accurate, current medication profile for one out of 14 sampled patients (Patient 1). This deficient practice had the potential to place Patient 1 at risk for medication errors and adverse drug reactions (when someone is harmed by a medicine). --- Findings: A review of Patient 1's admission record indicated Patient 1 was admitted to the hospice agency on 6/1/23, with a primary diagnosis of unspecified sequelae of cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). A review of Patient 1's "Plan of Care" dated 8/18/23, indicated the skilled nurse (SN) was to visit the patient to conduct the initial visit, recertification, certified home health aide (CHHA) supervisory visits if provided every 14 days, and license vocational nurse (LVN) supervisory visit if provided every 30 days. On 8/24/23, at 11 a.m., during a joint home visit with the License Vocational Nurse (LVN 1), Patient 1 was observed lying in a bed, awake, alert and well groomed. During Patient 1's medication review with LVN 1 compared with the medication profile, Levetiracetam 5 milligrams (ml) by mouth once a day was not listed on the medication profile. On concurrent review and interview with LVN 1 confirmed that Patient 1 had the bottle but did not understand why it was not listed on the medication profile. RN stated he will verify with the electronic medical record. During a medication profile review and interview with the DPCSD (director of patient care services) on 8/25/23, at 12:10 p.m., he stated that the admitting nurse should have reviewed the medication bottle with the med list per our policy. A review of the HA's undated policy titled "Medication Reconciliation" indicated the Hospice will reconcile patient's medication at time of admission and on an ongoing basis. Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication.

Based on interview and record review, the hospice agency (HA) failed to ensure the interdisciplinary group (IDG) meetings were held by all the members of interdisciplinary group to discuss the patients comprehensive and ongoing assessments and care planning process for four out of 14 sampled patients (Patient 8, Patient 9, Patient 10, and Patient 11). This deficient practice has the potential for the patients progress or decline will not be identified by the IDG, interventions will not be implemented, and patient care goals will not be achieved. --- Findings: a. A review of Patient 8's demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated he was admitted to the hospice agency on 5/17/23, with a terminal diagnosis of nontraumatic intracerebral hemorrhage (bleeding into the brain tissue) unspecified. A review of Patient 8s POC (Plan of Care) Summary, indicated an order dated 5/17/23, for continuous level of care (type of care that is a continuous 24-hour skilled nursing care provided by licensed medical professionals under the direct supervision of a physician). It also indicated an order for the Social Worker (MSW) to evaluate and assess patient's needs within 5 days of admission, and the Spiritual Care Coordinator (SC) for spiritual assessment within 5 days of admission to identify spiritual needs. A review of Patient 8s POC/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) meeting record, dated 5/17/23, indicated MSW and SC did not attend the meeting. b. A review of Patient 9's demographics indicated a start of care date of 4/22/23, with a terminal diagnosis of malignant neoplasm of tonsil (tonsil cancer, an abnormal growth of cells that forms in a tonsil). A review of Patient 9s POC Summary indicated an order dated 4/22/23, for the skilled nurse (SN) to visit the patient once a week, MSW to evaluate and assess for needs within 5 days of admission, and the SC for spiritual assessment within 5 days of admission to identify spiritual needs. A review of Patient 9s POC/IDG meeting record, dated 4/28/23, 5/26/23 and 6/23/23, indicated the Medical Director, Registered nurse (RN), MSW and SC did not sign the forms. c. A review of Patient 10's demographics indicated a start of care date of 7/13/23, with a terminal diagnosis of chronic respiratory failure with hypoxia (a condition in which your lungs have a hard time loading your blood with oxygen). A review of Patient 10s POC/IDG form dated 7/21/23, indicated the frequency of visits for skilled nurse to one visit per week, MSW to one visit for initial evaluation and as needed, and SC to one visit for initial evaluation and as needed. A review of Patient 10s POC/IDG meeting record, dated 7/21/23 and 8/4/23, indicated the Medical Director, Registered nurse (RN), MSW and SC did not sign the forms. d. A review of Patient 11's demographics indicated a start of care date of 5/8/23, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery (refers to the accumulation of plaque on the inner walls of blood vessels, and this plaque consists of substances found in the bloodstream, such as fat, cholesterol, and calcium) without angina pectoris (medical term for chest pain or discomfort due to coronary heart disease). A review of Patient 11s POC Summary indicated an order, dated 5/8/23, for the licensed vocational nurse (LVN) to visit the patient once a week, hospice aide (CHHA) to visit twice a week, MSW to evaluate and assess for needs within 5 days of admission, and the SC for spiritual assessment within 5 days of admission to identify spiritual needs. A review of Patient 11s POC/IDG meeting record indicated the RN, MSW and SC did not attend the meeting on 5/12/23 and 6/23/23. On 8/25/23, at 12:45 p.m., during a concurrent interview and record review with the Director of Patient Care Services Designee (DPCSD), DPCSD stated the IDG meeting is done every two weeks and the members include the Medical Director, Social Worker, Chaplain, and Registered Nurse. The DPCSD stated members who attended the meeting will electronically sign on the same day the meeting was held. The DPCSD was not able to provide documented evidence all the IDG members had participated in the IDG meetings for Patient 8, 9, 10, and 11 on the above days. A review of the agency's policy and procedure titled, "Interdisciplinary Group Meeting," revised April 2017, indicated the interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care. Each patients plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patients condition requires. Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor/Nursing Supervisor.

Based on interview and record review, the hospice agency failed to provide medical social services (services addressing social and emotional concerns related to the patient's illness and care) in accordance with the plan of care to four of 14 sampled patients (Patient 8, Patient 9, Patient 10, and Patient 11). This failure had the potential that the available services to support the psychosocial needs were not made available and accessible to the patients and family members under the hospice care. --- Findings: a. A review of Patient 8's demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated he was admitted to the hospice agency on 5/17/23, with a terminal diagnosis of nontraumatic intracerebral hemorrhage (bleeding into the brain tissue), unspecified. A review of Patient 8s POC (Plan of Care) Summary, indicated an order dated 5/17/23, for continuous level of care (type of care that is a continuous 24-hour skilled nursing care provided by licensed medical professionals under the direct supervision of a physician). It also indicated an order for the Social Worker (MSW) to evaluate and assess for needs within 5 days of admission, and the Spiritual Care Coordinator (SC) for spiritual assessment within 5 days of admission to identify spiritual needs. A review of Patient 8's clinical record did not indicate a documented psychosocial assessment (an evaluation of the psychological and social factors that are experienced by an individual or family) was completed since the start of care (SOC). b. A review of Patient 9's demographics indicated a start of care date of 4/22/23, with a terminal diagnosis of malignant neoplasm of tonsil (tonsil cancer, an abnormal growth of cells that forms in a tonsil). A review of Patient 9s POC Summary indicated an order dated 4/22/23, for the skilled nurse (SN) to visit the patient once a week, MSW to evaluate and assess for needs within 5 days of admission, and the SC for spiritual assessment within 5 days of admission to identify spiritual needs. A review of Patient 9's clinical record did not indicate a documented psychosocial assessment was completed since SOC. c. A review of Patient 10's demographics indicated a start of care date of 7/13/23, with a terminal diagnosis of chronic respiratory failure with hypoxia (a condition in which your lungs have a hard time loading your blood with oxygen). A review of Patient 10s POC/IDG form dated 7/21/23, indicated the frequency of visits for skilled nurse to one visit per week, MSW to one visit for initial evaluation and as needed, and SC to one visit for initial evaluation and as needed. A review of Patient 10's clinical record did not indicate a documented psychosocial assessment was completed since SOC. d. A review of Patient 11's demographics indicated a start of care date of 5/8/23, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery (refers to the accumulation of plaque on the inner walls of blood vessels, and this plaque consists of substances found in the bloodstream, such as fat, cholesterol, and calcium) without angina pectoris (medical term for chest pain or discomfort due to coronary heart disease). A review of Patient 11s POC Summary indicated an order, dated 5/8/23, for the licensed vocational nurse (LVN) to visit the patient once a week, hospice aide (CHHA) to visit twice a week, MSW to evaluate and assess for needs within 5 days of admission, and the SC for spiritual assessment within 5 days of admission to identify spiritual needs. A review of Patient 11's clinical record did not indicate a documented psychosocial assessment was completed since SOC. On 8/25/23, at 12:45 p.m., during a concurrent interview and record review with the Director of Patient Care Services Designee (DPCSD), DPCSD was not able to provide documented evidence the social worker had visited or conducted an assessment for Patient 8, Patient 9, Patient 10, and Patient 11. The DPCSD stated the social worker should have visited them and conducted an assessment within 5 days of admission. A review of the agency's policy and procedure titled, "Psychosocial Services," revised April 2017, indicated Victory Hospice Care, Inc will provide psychosocial services by qualified social workers under the direction of a physician and in accordance with the plan of care. Psychosocial assessments will be performed on each new admission. Psychosocial assessments and interventions will be documented in the patients clinical record as part of the comprehensive assessment and in interdisciplinary visit notes, as well as the plan of care.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Discharge Summary and the Report of Death and Disposal of Controlled Drug record was completed and signed, for one of 4 sampled discharged patients (Patient 8). This deficient practice resulted in the failure to document accurately and ensure authenticity of the patients clinical record. --- Findings: A review of Patient 8's demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated he was admitted to the hospice agency on 5/17/23, with a terminal diagnosis of nontraumatic intracerebral hemorrhage (bleeding into the brain tissue), unspecified. A review of Patient 8s Discharge Summary indicated an End of Care (EOC) date of 5/26/23 due to patients death. The discharge summary was not signed by the documenting nurse. The signature box was blank. A review of Patient 8s Report of Death and Disposal of Controlled Drugs form, dated 5/26/23, indicated medications were disposed per hospice policy and procedures. The form was not signed by the documenting nurse. The signature box was blank. On 8/25/23, at 12:15 p.m., during a concurrent interview and record review with the Registered Nurse (RN 1), RN 1 stated all patient clinical notes should be signed and dated on the day the treatment or service was made. RN 1 acknowledged the findings. A review of the agency's policy and procedure titled, "Entries into the Clinical Record", revised April 2017, indicated hospice personnel providing direct patient care and supervisory functions have authority to make entries into the clinical record. Clinical note will include: a. Care that was provided b. Treatment and/or invasive procedures performed c. Patient response to treatment and/or procedures d. The date the service was provided e. Signature of clinician and his/her credentials

Based on interview and record review, the hospice agency (HA) failed to ensure a discharge summary was completed and signed upon discharge for three of 4 sampled discharged patients (Patients 3, 8, and 9). This deficient practice has the potential to result in the patient's clinical information and documentation will not be conveyed that will assist in post-discharge continuity of care requested by the attending physician or receiving facility. --- Findings: a. A review of Patient 8's demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated he was admitted to the hospice agency on 5/17/23, with a terminal diagnosis of nontraumatic intracerebral hemorrhage (bleeding into the brain tissue), unspecified. A review of Patient 8s POC (Plan of Care) Summary, indicated an order dated 5/17/23, for continuous level of care (type of care that is a continuous 24-hour skilled nursing care provided by licensed medical professionals under the direct supervision of a physician). It also indicated an order for the Social Worker (MSW) to evaluate and assess for needs within 5 days of admission, and the Spiritual Care Coordinator (SC) for spiritual assessment within 5 days of admission to identify spiritual needs. A review of Patient 8s Discharge Summary indicated an End of Care (EOC) date of 5/26/23, due to patients death. The discharge summary was not signed by the documenting nurse. b. A review of Patient 9's demographics indicated a start of care date of 4/22/23, with a terminal diagnosis of malignant neoplasm of tonsil (tonsil cancer, an abnormal growth of cells that forms in a tonsil). A review of Patient 9s POC Summary indicated an order dated 4/22/23, for the skilled nurse (SN) to visit the patient once a week, MSW to evaluate and assess for needs within 5 days of admission, and the SC for spiritual assessment within 5 days of admission to identify spiritual needs. A review of Patient 9s Discharge Summary indicated an End of Care date of 7/2/23, due to patients death. The discharge summary was not signed by the documenting nurse. On 8/25/23, at 12:45 p.m., during a concurrent interview and record review with the Director of Patient Care Services Designee (DPCSD), DPCSD stated that patient who was discharged should have a complete discharge summary, so you know why they are being discharged. DPCS stated and acknowledged Patient 8 and Patient 9s discharge summary was not signed by the documenting nurse, and therefore was not complete. A review of the agency's policy and procedure titled, "Discharge Summary," revised April 2017, indicated each patient discharged from a service and from hospice will have a discharge summary filed in the clinical record. The discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from service. A review of the agency's policy and procedure titled, "Entries into the Clinical Record", revised April 2017, indicated hospice personnel providing direct patient care and supervisory functions have authority to make entries into the clinical record. Clinical note will include: a. Care that was provided b. Treatment and/or invasive procedures performed c. Patient response to treatment and/or procedures d. The date the service was provided e. Signature of clinician and his/her credentials A review of Patient 3's demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated he was admitted to the hospice agency on 6/13/23, with a terminal diagnosis of Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A review of Patient 3s POC (Plan of Care) Summary, indicated an order dated 8/4/23, indicated an order for the LVN (license vocational nurse) to visit once a week, the Social Worker (MSW) to evaluate and assess for needs within 5 days of admission, and the Spiritual Care Coordinator (SC) for spiritual assessment within 5 days of admission to identify spiritual needs. A review of Patient 3s Discharge Summary indicated an End of Care (EOC) date of 8/16/23, due to patient declining services. The discharge summary was not signed by the documenting nurse.

Observed in Individual Tracer. In 1 of 3 home visits conducted, HV/RR 1, during the record review the surveyor noted the organization failed to show evidence the assessment included wound measurements. For example, the initial assessment indicated the patient had a stage II pressure ulcer on the coccyx, however there was no evidence the wound had been measured by the nurse. This was validated by the QA Nurse.

Observed in Individual Tracer. In 1 of 3 home visits conducted, HV3, during the home visit the surveyor noted the organization failed to assess for potential medication-related problems. For example, HV3, the nurse failed to conduct an effective medication reconciliation as she did not compare the medication bottles, including the comfort kit to the organization's medication list. The nurse stated the patient had a comfort kit, however it was in a locked box and the key was not available. The medication list did not include any comfort kit medications. This was not compliant with the organization's Medication Reconciliation Policy. This was validated by the Assistant Administrator.

Observed in Individual Tracer. In 1 of 3 home visits conducted, HV/RR1 during the record review the surveyor noted the organization failed to show evidence it planned the patient’s care, treatment, or services based on needs identified by the patient's assessment. For example, the patient's initial assessment indicated a pressure ulcer on the coccyx, however there was no problem or intervention related to the skin integrity identified on the initial plan of care. This was validated by the QA Nurse.

Observed in Individual Tracer. In 1 of 3 home visits conducted, HV3, the organization failed to implement infection prevention and control activities when cleaning equipment. For example, HV3 after cleaning the blood pressure cuff, the nurse placed it on the dirty side of her barrier field prior to placing it back into the bag. This was not compliant with standard precautions policy and confirmed by the QA RN. Observed in Individual Tracer. In 1 of 3 home visits conducted, HV1, the organization failed to demonstrate it used standard precautions to reduce the risk of infection. For example, HV1, the aide used disinfectant wipes to clean his hands rather than hand sanitizer. This was not compliant with the organization's Hand Hygiene policy.

Observed in Individual Tracer. In 1 of 1 hospice aide visits, HV1, the organization failed to treat the patient in a dignified and respectful manner. For example, HV1, during the bed bath, the aide failed to close the doors (2 sets) prior to and while providing the bed bath. In addition he left the patient exposed when he went left the room to refill the water basin. This was validated by the Assistant Administrator.

Observed in Leadership Session. The Governing Body failed to ensure the following Conditions of Participation had been met as determined through observation, documentation and staff interviews: 418.116 Observed in Individual Tracer. During the bereavement program session with the coordinator, the surveyor noted the Bereavement Program policy stated that monthly mailings would be sent to all survivors. However, during subsequent record review, the plans of care did not match the mailing frequencies stated in the policy.

Observed in Individual Tracer. In 1 of 3 home visits conducted, HV/RR2 and subsequent record review the surveyor noted the organization failed to implement it's policy regarding the disposition of controlled substances. For example, in HV/RR2 the comfort kit was disposed of by the skilled nurse and a new kit was ordered; however, there was no documentation regarding the reason for the disposal of the kit or the disposition of the medications. This was not compliant with the organization's Use and Disposal of Controlled Substances and validated by the QA RN and QAPI Coordinator.

Observed in Document Review. The surveyor noted the organization's state license expired on 12/26/22. The organization was unable to produce documentation of a current license at the time of survey. This was validated by the Owner/Administrator.