Every finding on record at Visiting Nurse Service of New York Hospice Care

Based on clinical record reviews and staff interview, the hospice failed to ensure that Hospice Aides provide services in accordance with the Paraprofessional Plan of Care. This was evident for one (1) of three (3) clinical records reviewed (Patient #1). Failure to ensure all Hospice Aides provide services in accordance with the Paraprofessional Plan of Care, has the potential for negative patient outcomes. The Findings Are: --- 1. Patient #1 has Start of Care date of 10/20/2025 with the following diagnoses “Heart Failure, Chronic Obstructive Pulmonary Disease, Unspecified Asthma with (Acute) Exacerbation” documented on the Hospice Certification and Plan of Care for Certification Periods 10/20/2025 to 01/17/2026. The Paraprofessional Plan of Care for 10/20/2025 to 01/17/2026 documents the following tasks: “Bath: Sponge, Dressing, Incontinent care, Laundry, Clean” The Duty Sheet dated 11/4-11/7 documents the following tasks: “B/P (Blood Pressure), Respiration, Pulse, Walking: Assist, Assist with Feeding.” There is no documented evidence of the Hospice Aides providing services in accordance with the Paraprofessional Plan of Care. On 12/18/2025 at 12:30 PM, the Hospice Quality Manager was interviewed and did not provide an explanation for the findings.

Based on clinical record reviews and staff interview, the hospice failed to ensure that Hospice Aides report all concerns about the patient or family. This was evident for one (1) of three (3) clinical records reviewed.  (Patient #1). Failure to ensure that all concerns are reported, has the potential for negative patient outcomes. The Findings Are: --- 1. Patient #1 has Start of Care date 10/20/2025 with the following diagnoses “Heart Failure, Chronic Obstructive Pulmonary Disease, Unspecified Asthma with (Acute) Exacerbation” documented on the Hospice Certification and Plan of Care for Certification Periods 10/20/2025 to 01/17/2026. The Paraprofessional Plan of Care for 10/20/2025 to 01/17/2026 documents following tasks: “Bath: Sponge.” The investigation summary dated 12/17/25, at 10:05 AM documents: “(Employee #1) statement: Upon arrival at 9:00 AM, the patient was seated in a chair. The daughter instructed the aide to give the patient a shower. The aide asked the patient immediately, but he refused. When asked again as he exited the bathroom, the patient said yes in two hours. The aide informed the daughter of the refusal, and she acknowledged that the patient dislikes showers and had not showered for at least two weeks. She requested the aide to try again later.” The clinical record lacks documented evidence of Employee #1 notifying the agency that patient’s family requesting completion of the task that is not a part of the Paraprofessional Plan of Care. On 12/18/2025 at 12:30 PM, the Hospice Quality Manager was interviewed and did not provide an explanation for the findings.

Based on clinical record reviews and interviews, the hospice failed to ensure all individualized Plan of Care(s) are followed. This was evident for one (1) of three (3) clinical records reviewed (Patient #1).Failure to ensure that an individualized Plan of Care is followed, has the potential for negative patient outcomes.The finding is:1. Patient #1 has a Start of Care date of 10/15/2025 with the following diagnoses "Malignant Neoplasm of Pancreas with Hepatic Metastases” documented on the Hospice Certification and Plan of Care for the Certification Period 10/15/2025 to 01/12/2026.The Hospice Physician Order dated 10/18/2025 documents: HHA (Home Health Aide) Service “21 HRS/WEEK (Twenty-one hours a week). Service Changes: Calendar Frequency: HHA (Home Health Aide) Effective 10/19/2025 6WK1, 7WK11, 2WK1 (Six times a week for one week, seven times a week for eleven weeks, twice a week for one week)”.The Hospice Physician Order dated 10/22/2025 documents: HHA (Home Health Aide) Service 12 HRS 8 PM to 8 AM (Twelve hours from eight o’clock in the evening to eight o’clock in the morning) 10/22, 10/23, 10/24.The Duty Sheet by Visit Date documents aide services being provided on: 10/22/2025. The clinical record lacks documented evidence of aide providing services for the week of: 10/19/2025 to 10/25/2025 – missed three visits. There is no documented evidence of the patient receiving aide services as ordered in the plan of care.On 11/06/2025 at 03:40 PM, the Administrators and Quality improvement Manager were interviewed and did not provide an explanation for the findings.

Based on clinical record reviews and staff interviews, the hospice failed to ensure comprehensive assessments identifies all the patient's needs. This was evident for two (2) of thirty (30) clinical records reviewed. (Patients #11, and #25). Failure to ensure that a comprehensive assessment identifies all the patient 's needs has the potential for negative patient outcomes. The Findings Are: --- 1. Patient #11 has a Start of Care date of 09/09/2024 with the following diagnoses "Malignant Neoplasm of Ovary, Anxiety Disorder" documented on the Hospice Certification and Plan of Care for the Certification Period 09/09/2024 to 12/07/2024. The Visit Note Report dated 09/09/2024, 09/10/2024, 09/12/2024, 09/16/2024, 09/17/2024, 09/18/2024, and 09/23/2024 documents: ";Does the patient have infusion access: NO." The Visit Note Report dated 09/23/2024 documents: Does the patient have infusion access: YES; Type of infusion access: Port, implanted, vascular access port; Indicate when port was last accessed: accessed prior to visit; Indicate date when port was last accessed: 3 weeks ago. The Initial assessment and comprehensive assessments before 09/23/2024 lacks documented evidence of the chest port. On 10/18/2024 at 03:00 PM, the Administrators/Directors of Clinical Services/ Directors of Patient Services (Senior Vice President Hospice and Palliative Care, Vice President Clinical Operations) and staff were interviewed and did not provide an explanation for the findings. 2. Patient #25 has a Start of Care date of 01/09/2024 and a discharge date of 01/30/2024 with the following diagnoses "Heart Failure, Vascular Dementia" documented in the Hospice Certification and Plan of Care for the Certification Period 01/09/2024 to 04/07/2024. The Hospice Certification and Plan of Care for the Certification Period 01/09/2024 to 04/07/2024 documents: ";Hospice nurse to perform the following wound care to pu (pressure ulcer) to Sacrum." The Visit Note Report (Hospice Admission assessment) dated 01/09/2024 documents: Mid Sacral pressure ulcer Injury; Unable to measure; No granulation tissue present; Epithelialization: <25% wound covered; Necrotic Tissue Amount: None visible." The Hospice Physician Order dated 01/12/2024 documents: ";Hospice Nurse to perform the following wound care to pu (pressure ulcer) to Sacrum utilizing clean technique – Cleanse with soap and water pat dry, apply Barrier Cream to surrounding skin, leave open to air, apply MediHoney to Stage III open area and cover with Foam bordered gauze pad. The Initial / comprehensive assessments lack documented evidence of a wound assessment that includes staging, measurement, and description as documented in the Hospice Physician Order. On 10/18/2024 at 03:00 PM, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings.

Based on clinical record reviews and staff interviews, the hospice failed to ensure that all comprehensive assessments are updated. This was evident for four (4) of thirty (30) clinical care records reviewed (Patient #1, #9, #10, and #12). Failure to ensure that all comprehensive assessment are updated, has the potential for negative patient outcomes. The Findings Are: --- *. Patient #9 has a Start of Care date of 08/01/2023 with the following diagnosis "Senile Degeneration of Brain" documented in the Hospice Certification of Terminal Illness for the Certification Period 07/26/2024 to 09/23/2024 and 09/24/2024 to 11/22/2024. The clinical record documents registered nurse visit on 09/05/2024, 09/26/2024 (21 days), and 10/18/2024 (22 days). The clinical record lacks documented evidence of an update of the comprehensive assessment that includes patients progress toward desired outcomes and response to care no less frequently than every 15 days. On 10/17/2024 at 02:35pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. *. Patient #10 has a Start of Care date of 09/03/2024 with the following diagnoses "Alzheimers Disease, Dementia" documented in the Hospice Certification of Terminal Illness for the Certification Period 09/03/2024 to 12/01/2024. The Plan of Care Update dated 09/17/2024 documents: Hospice nurse to perform wound care one time a week to Unstageable wound in Left Heel area. Utilizing clean technique – cleanse with Normal Saline, apply Iodine and pad with gauze cover with a Silicone Foam or Composite Dsg BIW & PRN (dressing twice a week and as needed). The Visit Note Report documents Left Heel, Unstageable DTI (deep tissue injury):09/17/2024 Epithelialization: <25%; slough: 76-100%; Eschar: 76-100%.10/08/2024 Epithelialization: 75-<100%; Necrotic amount: None. The clinical record lacks documented evidence of the update of wound by staging wound, necrosis resolved, only epithelialization.There is no documented evidence of an updated comprehensive assessment. On 10/17/2024 at 02:35pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. *. Patient #12 has a Start of Care date of 04/05/2024 with the following diagnosis "Senile Degeneration of Brain" documented in the Hospice Certification of Terminal Illness for the Certification Period 07/04/2024 to 10/01/2024. The Hospice Recertification Plan of Care Update for the Certification Period 07/04/2024 to 10/01/2024 documents: ";Hospice nurse to perform the following wound care to (pressure ulcer to Sacrum). Utilizing clean technique – Cleanse Stage 3 pressure ulcer with NS (normal saline), pat dry apply MediHoney to wound bed, and Zinc Oxide to periwound cover with Opti Foam and change q (every) shift and PRN (as needed)." The Visit Note Report (Recertification Assessment) dated 06/14/2024 documents: ";Does the patient have active wounds? NO; No additional integumentary assessment findings." The Visit Note Report dated 07/09/2024, 07/15/2024, 07/23/2024 documents: ";Does the patient have active wounds? NO; Additional Integumentary Observation Findings: No problems identified." The comprehensive assessment lacks documented evidence of the update of wound – no wound. The Visit Note Report documents: 08/01/2024 Mid Posterior Sacral pressure ulcer stage III. Reactivate wound – recurrence (no measurement or description of wound).08/09/2024 (no measurement or description of wound).08/16/2024 Mid Posterior Sacral pressure ulcer stage III; Epithelialization: 75-<100%; Necrotic Tissue Amount: None.08/21/2024 (no measurement or description of wound).08/27/2024 Mid Posterior Sacral pressure ulcer stage III; Epithelialization: 75-<100%; Necrotic Tissue Amount: None.09/10/2024 Mid Posterior Sacral pressure ulcer stage III; Granulation Tissue: 75-100%; Epithelialization: 100%; Necrotic Tissue Amount: None.09/18/2024 and 09/28/2024 (no measurement or description of wound). The comprehensive assessments lack documented evidence of the wound assessment and response to care every 15 days.There is no documented evidence of an updated comprehensive assessment. On 10/18/2024 at 03:00pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. 1. Patient #1 has a Start of Care date of 07/14/2024 with diagnosis of Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung documented in the "Hospice Certification and Plan of Care" for Certification Period 07/14/2024 to 10/11/2024. The "Hospice Certification and Plan of Care" for Certification Period 07/14/2024 to 10/11/2024 documents: ";Hospice RN (Registered Nurse) to evaluate patient and develop a nursing plan of care in collaboration and in agreement with the patient/representative." The Skilled Nurse/Registered Nurse ";Visit Note Report" dated 08/02/2024 documents: ";Patient has a rash between buttocks that appears to be vulnerable to pressure from sitting on wheelchair all day. Skin carefully monitored by RN (Registered Nurse) over next few weeks." The Registered Nurse Recertification Assessment ";Visit Note Report" dated 09/20/2024 documents: ";Patient is spending much more time in bed or sitting in his chair and has developed what appears to be a stage two pressure ulcer over coccyx. At time of charting nurse awaiting word from wound care (consult) as to how to address the wound. For the time being patient is using silicone bordered phone (foam) patches to pad area affected and offloading whenever possible." The Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report for meeting Date 09/24/2024 lacks documented evidence of the patient developing a stage two pressure ulcer over the coccyx. The ";Initial and Comprehensive Assessment" Policy (Revised April 2024) documents: the comprehensive assessment includes assessment of ";skin integrity (including a full assessment of wounds)." The ";Wound Assessment and Escalation" Policy (Revised April 2023) documents: A comprehensive wound assessment includes a clinical evaluation of the wound bed, periwound, and each risk factor;" timeframe for wound assessment is ";at the time of the onset of a new wound;" ";the size of the wound is measured once weekly as tolerated." The Registered Nurse Recertification Assessment ";Visit Note Report" dated 09/20/2024 and the subsequent weekly Skilled Nurse/Registered Nurse Visit Note Report(s) dated 09/27/2024 and 10/04/2024 lacks documented evidence of a comprehensive wound assessment, including measurement, in accordance with the agencys policies. The clinical record lacks documented evidence of the hospice nurse updating the comprehensive assessment to reflect changes in the patient's skin integrity, including at onset of a new wound and an ongoing wound comprehensive assessment. On 10/17/2024 at 2:35pm, the Administrator, the Vice President of Quality, the Directors of Clinical Services/Directors of Patient Services, and staff were interviewed and did not provide an explanation for the survey findings.

Based on clinical record reviews and interviews, the hospice failed to ensure all individualized Plan of Care(s) are followed. This was evident for two (2) of thirty (30) clinical records reviewed. (Patients #3, and #11). Failure to ensure that an individualized Plan of Care is followed, has the potential for negative patient outcomes. The Findings Are: --- *. Patient #11 has a Start of Care date of 09/09/2024 with the following diagnoses "Malignant Neoplasm of Ovary, Anxiety Disorder" documented in the Hospice Certification and Plan of Care for the Certification Period 09/09/2024 to 12/07/2024. The Hospice Physician Order dated 09/09/2024 documents: hha (home health aide) "3WK1, 5WK12 (three times a week for one week, five times a week for twelve weeks)". The Duty Sheet by Visit Date documents aide services being provided on: 09/11/2024, 09/13/2024, 09/16/2024, 09/18/2024, and 09/20/2024. The clinical record lacks documented evidence of aide providing services for the week of: 09/09/2024 to 09/14/2024 – missed one visits, 9/15/2024 to 09/21/2024 – missed two visits. There is no documented evidence of the patient receiving aide services as ordered in the plan of care. On 10/18/2024 at 03:00pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. 1. Patient #3 has a Start of Care date of 09/01/2024 with diagnoses of Malignant Neoplasm of Colon Unspecified, Secondary Malignant Neoplasm of Retroperitoneum and Peritoneum, Constipation Unspecified, Chronic Embolism and Thrombosis of Unspecified Deep Veins of Unspecified Lower Extremity documented in the "Hospice Certification and Plan of Care" for Certification Period 09/01/2024 to 11/29/2024. The Plan of Care Update dated 09/03/2024 documents: ";Home Health Aide for assistance with personal care, hygiene and activities of daily living; (home health aide) frequency 5Days x 2 Hours (five days a week times two hours a day)." The vendor Coordination Note – Home Health Aide Request dated 09/03/2024 documents the following request: ";(Home Health Aide) Order schedule ";5 Days x 2 Hours (Mon-Fri) 3PM-5PM;" and ";Start Date requested: 9/4/2024." The ";Duty Sheet By Visit Date" dated 09/01/2024 to 09/30/2024 documents aide services started on 09/13/2024, not on 09/04/2024 as requested. The clinical record lacks documented evidence of communication with the patient/family regarding the delay providing home health aide services. The ";Duty Sheet By Visit Date" dated 09/01/2024 to 09/30/2024 and 10/01/2024 to 10/16/2024 lacks documented evidence of home health aide services being provide on 09/23/2024 (Monday), 10/07/2024 (Monday), and 10/08/2024 (Tuesday). The Coordination Note dated 09/24/2024 documents: ";(patient family member) is not happy that no one showed up yesterday (09/23/2023). They (Family/patient) leave the door open for the evening aide. (Family member) does not want to continue leaving the door open if no one will show up. (The caller) also stated the aide needs to change the patient before leaving. (Family) has a camera & no one has changed the pt(patient) before leaving." There is no documented evidence of the collaboration and notification of the missed visits to the Physician and patient/family. There is no documented evidence of home health aide services being furnished in accordance with the hospice plan of care and the patients needs. On 10/17/2024 at 2:35pm, the Administrator, the Vice President of Quality, the Directors of Clinical Services/Directors of Patient Services, and staff were interviewed and did not provide an explanation for the survey findings.

Based on clinical record reviews and interviews, the hospice failed to ensure that each patient and the primary care giver(s) receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care. This was evident for one (1) of thirty (30) clinical records reviewed. (Patients #1). Failure to ensure that each patient and the primary care giver(s) receive education, has the potential for negative patient outcomes. The Findings Are: --- 1. Patient #1 has a Start of Care date of 07/14/2024 with diagnosis of Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung documented in the "Hospice Certification and Plan of Care" for Certification Period 07/14/2024 to 10/11/2024. The Skilled Nurse/Registered Nurse ";Visit Note Report" dated 08/02/2024 documents: ";Patient has a rash between buttocks that appears to be vulnerable to pressure from sitting on wheelchair all day. Skin carefully monitored by RN (Registered Nurse) over next few weeks." The RN (Registered Nurse) Recertification Assessment ";Visit Note Report" dated 09/20/2024 documents: ";Patient is spending much more time in bed or sitting in his chair and has developed what appears to be a stage two pressure ulcer over coccyx." The clinical record lacks documented evidence of the skilled nurse educating the patient/primary care giver(s) on how to prevent the patient from developing a pressure ulcer. On 10/17/2024 at 2:35 PM the Administrators/Directors of Clinical Services/ Directors of Patient Services (Senior Vice President Hospice and Palliative Care, Vice President Clinical Operations) and staff were interviewed and did not provide an explanation for the survey finding.

Based on clinical record reviews and staff interviews, the hospice failed to ensure individualized Plan of Care is developed for each patient. This was evident for one (1) of thirty (30) clinical records reviewed. (Patients #12). Failure to ensure that individualized Plan of Care is developed for each patient, has the potential for negative patient outcomes. The Findings Are: --- 1. Patient #12 has a Start of Care date of 04/05/2024 with the following diagnosis "Senile Degeneration of Brain" documented in the Hospice Certification of Terminal Illness for the Certification Period 07/04/2024 to 10/01/2024. The Hospice Recertification Plan of Care Update for the Certification Period 07/04/2024 to 10/01/2024 documents: ";Hospice nurse to perform the following wound care to (pressure ulcer) to Sacrum. Utilizing clean technique – Cleanse Stage 3 pressure ulcer with NS (normal saline), pat dry apply MediHoney to wound bed, and Zinc Oxide to periwound cover with Opti Foam and change q (every) shift and PRN (as needed)." The Visit Note Report (Recertification Assessment) dated 06/14/2024 documents: ";Does the patient have active wounds? NO; No additional integumentary assessment findings." The Visit Note Report dated 07/09/2024, 07/15/2024, 07/23/2024 documents: ";Does the patient have active wounds? NO; Additional Integumentary Observation Findings: No problems identified." The Plan of Care lacks documented evidence of the updated status of - no wound. On 10/18/2024 at 03:00 PM, the Administrators/Directors of Clinical Services/ Directors of Patient Services (Senior Vice President Hospice and Palliative Care, Vice President Clinical Operations) and staff were interviewed and did not provide an explanation for the findings.

Based on clinical record reviews and staff interviews, the hospice failed to ensure the individualized Plan of Care includes all medication and treatments as ordered by the Physician . This was evident for two (2) of thirty (30) clinical records reviewed. (Patients #1, and #19). Failure to ensure the individualized Plan of Care includes all medication and treatments as ordered by the physician for each patient has the potential for negative patient outcomes. The Findings Are: --- 1. Patient #19 (Home Visit) has a Start of Care date of 9/16/2024 with diagnoses of Malignant Neoplasm of Biliary Tract, Unspecified documented on the Hospice Certification and Plan of Care with a Certification Period from 9/16/2024 to 12/14/2024. On 10/15/2024 a Home Visit was conducted, and the oxygen safety sign was observed on the Patient #19s bedroom door and the oxygen concentrator were present in the Patient #19s bathroom. The LPN (Licensed Practical Nurse) was interviewed and stated Patient #19 can use the oxygen whenever he needs it. There is no documented evidence of Physicians Order for the use of oxygen. On 10/17/2024 at 02:35pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. 1. Patient #1 has a Start of Care date of 07/14/2024 with diagnosis of Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung documented in the "Hospice Certification and Plan of Care" for Certification Period 07/14/2024 to 10/11/2024. The Skilled Nurse/Registered Nurse ";Visit Note Report" dated 08/02/2024 documents: ";Patient has a rash between buttocks that appears to be vulnerable to pressure from sitting on wheelchair all day. Skin carefully monitored by RN (Registered Nurse) over next few weeks." The Registered Nurse Recertification Assessment ";Visit Note Report" dated 09/20/2024 documents: ";Patient is spending much more time in bed or sitting in his chair and has developed what appears to be a stage two pressure ulcer over coccyx. At time of charting nurse awaiting word from wound care (consult) as to how to address the wound. For the time being patient is using silicone bordered phone (foam) patches to pad area affected and offloading whenever possible." The NP (Nurse Practitioner) Wound Care Consult Coordination Note dated 09/23/2024 documents: ";Consult Request Date: 9-20-24 Time: 2:04PM;" ";Recommendations/Verbal Order Given: Date 9-20-24 Time: 2:37PM;" ";Received picture of sacral area with what appears to be a Stage 3 PI (Pressure Injury) from (Registered Nurse/Skilled Nurse);" ";Recommendations: Wound cleansee, a dab of honey wound gel to the wound, skin prep to protect periwd (periwound), pad with gauze, cover with a silicone foam or composite dsg (dressing) BIW (twice a week) & PRN (as needed), offload;" ";reinforce pressure injury prevention measures as appropriate." The NP (Nurse Practitioner) Coordination Note documents that a verbal order for wound care was given on 09/20/2024. The NP (Nurse Practitioner) Wound Care Consult Coordination Note dated 09/26/2024 documents: ";Consult Request Date: 9-25-24 Time: 3:55PM;" ";Recommendations/Verbal Order Given: Date 9-25-24 Time: 3:57PM;" ";Received additional picture of Sacral Stage 3 PI (Pressure Injury) form (Registered Nurse/Skilled Nurse);" ";Recommendations: Continue honey wound gel, periwound protection BIW (twice a week) & PRN (as needed), ongoing offloading." The subsequent weekly Skilled Nurse/Registered Nurse Visit Note Report(s) dated 09/27/2024 and 10/04/2024 lacks documented evidence of the Skilled nurse performing wound care. The clinical record lacks documented evidence of wound care being performed twice a week. The Hospice Physician Order dated 10/10/2024 documents the Skilled Nurse/Registered Nurse entered the recommendations/verbal order for wound care twenty (20) days after the order was given. The Hospice Physician Order dated 10/10/2024 documents the following wound care order: ";Using Clean technique, cleanse wound with normal saline or wound cleanser, apply a dab of medical honey, apply a piece of gauze to wound, apply barrier film to periwound and cover with silicone foam dressing. Perform wound care biweekly (twice a week) or PRN (as needed). VNS nurses will perform wound care during weekly visit." There is no documented evidence of the Skilled Nurse immediately documenting the verbal orders for wound care to ensure plan of care is revised and the patients wound care needs are addressed in a timely manner. On 10/17/2024 at 2:35pm, the Administrator, the Vice President of Quality, the Directors of Clinical Services/Directors of Patient Services, and staff were interviewed and did not provide an explanation for the survey findings.

Based on clinical record reviews and staff interviews, the hospice failed to ensure the Plan of Care includes medical supplies and appliances necessary to meet the needs of the patient. This was evident for one (1) of thirty (30) clinical records reviewed. (Patients #7). Failure to ensure that Plan of Care includes medical supplies and appliances necessary to meet the patient needs, has the potential for negative patient outcomes. The Findings Are: --- 1. Patient #7 has a Start of Care date of 08/22/2024 with the following diagnosis "Diffuse Large B-Cell Lymphoma" documented in the Hospice Certification and Plan of Care for the Certification Period 08/22/2024 to 11/19/2024. The Hospice Certification and Plan of Care for the Certification Period 08/22/2024 to 11/19/2024 documents: DME (durable medical equipment): wheelchair. The Visit Note Report dated 08/22/2024 documents: Existing equipment / supplies owned by patient: cane, walker, shower stool. The Plan of Care lacks documented evidence of the cane, walker and the shower stool. On 10/17/2024 at 02:35 PM the Administrators/Directors of Clinical Services/ Directors of Patient Services (Senior Vice President Hospice and Palliative Care, Vice President Clinical Operations) and staff were interviewed and did not provide an explanation for the findings.

Based on clinical record reviews and staff interviews, the hospice failed to ensure the Interdisciplinary Group reviewed and revised the individualized Plan of Care as the patient's care needs change, but no less frequently than every fifteen (15) days. This was evident for eight (8) of thirty (30) clinical records reviewed. (Patients #1, #3, #6, #9, #10, #12, #16, and #20). Failure to ensure that the Interdisciplinary Group develop, review, and revise the POC, has the potential for negative patient outcomes. The Findings Are: --- *. Patient #9 has a Start of Care date of 08/01/2023 with the following diagnosis "Senile Degeneration of Brain" documented in the Hospice Certification of Terminal Illness for the Certification Period 07/26/2024 to 09/23/2024 and 09/24/2024 to 11/22/2024. The Client Episode Coordination Notes Report dated 07/28/2024 documents: ";Patient who is constipated for 8 days" ";Patient is not in pain related to BM (bowel movement) but is having pain to hip" ";she is very concerned about the new onset of pain to hip". The Hospice Physician Order dated 07/28/2024 documents: ";Add Bisacodyl daily for constipation as needed; Add Lactulose 30 ml (milliliter) daily." New order Morphine Concentrate 10mg every 2 hours/PRN (as needed) and discontinue Morphine 5 mg every 2 hours//PRN (as needed). The Hospice IDG (Interdisciplinary group) Comprehensive Assessment and Plan of Care Update Report dated 08/07/2024 documents: Summary of updates/issues/status/decline over the prior two weeks: blank. The Interdisciplinary group meeting on 07/24/2024 and 08/07/2024 lacks documented evidence of the review of the outcome of increasing pain medication and started on constipation medication. On 10/17/2024 at 02:35pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. *. Patient #10 has a Start of Care date of 09/03/2024 with the following diagnoses "Alzheimers Disease, Dementia" documented in the Hospice Certification of Terminal Illness for the Certification Period 09/03/2024 to 12/01/2024. The Client Episode Coordination Notes Report documents:09/23/2024 ";Pt (patient) is now interested in volunteer services" ";Pts (patients) daughter is also interested in receiving a Hoyer Lift since it has become increasingly difficult to transfer pt (patient)."10/14/2024 ";Pts (patients) dtr (daughter) expressed dissatisfaction with current hha (home health aide)." The Interdisciplinary group lacks documented evidence in reviewing, revising, and providing the need for volunteer, Hoyer Lift, and aide services. The Visit Note Report documents Left Heel, Unstageable DTI (deep tissue injury):09/17/2024 Epithelialization: <25%; slough: 76-100%; Eschar: 76-100%.10/08/2024 Epithelialization: 75-<100%; Necrotic amount: None. The Hospice IDG (Interdisciplinary group) Comprehensive Assessment and Plan of Care Update Report dated 10/09/2024 documents: ";Patient has bedsore unstageable wound in left heel area, no drainage, no infection." The Interdisciplinary group lacks documented evidence in reviewing and revising the plan of care with wound improvement and staging of pressure ulcer. The Hospice Certification of Terminal Illness for the Certification Period 09/03/2024 to 12/01/2024 documents: hha (home health aide) 1WK1, 3WK12 (once a week for one week, three times a week for twelve weeks). The Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report dated 09/11/2024, 09/25/2024, and 10/09/2024 documents: No hha (home health aide) service. MLTC (Managed Long Term Care) 7D x 24H. The Duty Sheet by Visit Date documents aide services being provided on 09/09/2024, 09/11/2024, 09/13/2024, 09/18/2024, 09/25/2024, 09/27/2024, 09/30/2024, 10/02/2024, 10/04/2024, 10/07/2024, 10/09/2024, and 10/11/2024. The Interdisciplinary group lacks documented evidence in reviewing and revising the plan of care with aide services being provided by hospice and not with MLTC (Managed Long Term Care). On 10/17/2024 at 02:35pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. *. Patient #12 has a Start of Care date of 04/05/2024 with the following diagnosis "Senile Degeneration of Brain" documented in the Hospice Certification of Terminal Illness for the Certification Period 07/04/2024 to 10/01/2024. The Hospice Recertification Plan of Care Update for the Certification Period 07/04/2024 to 10/01/2024 documents: ";Hospice nurse to perform the following wound care to (pressure ulcer to Sacrum). Utilizing clean technique – Cleanse Stage 3 pressure ulcer with NS (normal saline), pat dry apply MediHoney to wound bed, and Zinc Oxide to periwound cover with Opti Foam and change q (every) shift and PRN (as needed)." The Visit Note Report (Recertification Assessment) dated 06/14/2024 documents: ";Does the patient have active wounds? NO; No additional integumentary assessment findings." The Visit Note Report dated 07/09/2024, 07/15/2024, 07/23/2024 documents: ";Does the patient have active wounds? NO; Additional Integumentary Observation Findings: No problems identified." The Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report dated 07/17/2024 and 07/31/2024 lacks documented evidence in reviewing and revising/ discontinuation of the wound order (no wound). The plan of care lacks documented evidence of an accurate order for wound treatment, patient have no pressure ulcer. The Visit Note Report documents: 08/01/2024 Mid Posterior Sacral pressure ulcer stage III. Reactivate wound – recurrence (no measurement or description of wound).08/09/2024 (no measurement or description of wound).08/16/2024 Mid Posterior Sacral pressure ulcer stage III; Epithelialization: 75-<100%; Necrotic Tissue Amount: None.08/21/2024 (no measurement or description of wound).08/27/2024 Mid Posterior Sacral pressure ulcer stage III; Epithelialization: 75-<100%; Necrotic Tissue Amount: None.09/10/2024 Mid Posterior Sacral pressure ulcer stage III; Granulation Tissue: 75-100%; Epithelialization: 100%; Necrotic Tissue Amount: None.09/18/2024 and 09/28/2024 (no measurement or description of wound). The Interdisciplinary group lacks documented evidence in reviewing and revising the wound staging and the progress of the wound every 15 days. On 10/18/2024 at 03:00pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. 3. Patient #20 has a Start of Care date of 7/02/2024 with diagnoses of Chronic Kidney Disease, Stage 5 documented on the Hospice Recertification and Plan of Care with a Certification Period from 9/30/2024 to 12/28/2024. The Routine Visit dated 10/01/2024 documents: ";Skin pale, clean, dry, and intact. Has sacral erythema R/T (related) incontinence. FES (caregiver) washes site with soap and water and applies Zinc Oxide cream daily and PRN (as needed). The Routine Visit dated 10/08/2024 documents: ";Skin pale, clean, dry, and intact. Sacral erythema persists R/T (related) incontinence. FES (caregiver) continues to apply Zinc Oxide cream daily after washing with soap and water to prevent skin brake." There is no documented evidence of the Physicians Order for medication to be used to sacral erythema. There is no documented evidence of the IDG (Interdisciplinary Group) reviewing and revising the patients individualized plan of care at least every 15 days or as needed that includes medications and treatments. On 10/17/2024 at 02:35pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. *Patient #16 has a Start of Care date of 09/06/2024 with the following diagnoses "Other Sequelae of Cerebral Infarction, Depression, Essential (primary) Hypertension" documented on the Hospice Recertification and Plan of Care for the Certification Period 09/06/2024 to 12/04/2024. The clinical record documents Interdisciplinary Group meetings on 09/11/2024 and 10/02/2024. (greater than 15 days) There is no documented evidence of the Interdisciplinary Group reviewing and revising the Plan of Care at least every 15 calendar days. On 10/17/2024 at 02:35 pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. 1. Patient #1 has a Start of Care date of 07/14/2024 with diagnosis of Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung documented in the "Hospice Certification and Plan of Care" for Certification Period 07/14/2024 to 10/11/2024. The "Hospice Certification and Plan of Care" for Certification Period 07/14/2024 to 10/11/2024 documents: ";Hospice RN (Registered Nurse) to evaluate patient and develop a nursing plan of care in collaboration and in agreement with the patient/representative." The RN (Registered Nurse) Recertification Assessment ";Visit Note Report" dated 09/20/2024 documents: ";Patient is spending much more time in bed or sitting in his chair and has developed what appears to be a stage two pressure ulcer over coccyx. At time of charting nurse awaiting word from wound care (consult) as to how to address the wound. For the time being patient is using silicone bordered phone (foam) patches to pad area affected and offloading whenever possible." The NP (Nurse Practitioner) Wound Care Consult Coordination Note dated 09/23/2024 documents: ";Consult Request Date: 9-20-24 Time: 2:04PM;" ";Recommendations/Verbal Order Given: Date 9-20-24 Time: 2:37PM;" ";Received picture of sacral area what appears to be a stage 2 PI (Pressure Injury) from (Skilled Nurse);" ";Recommendations: Wound cleanse, a dab of honey wound gel to the wound, skin prep to protect periwd (periwound), pad with gauze, cover with a silicone foam or composite dsg (dressing) BIW (twice a week) & PRN (as needed), offload;" ";reinforce pressure injury prevention measures as appropriate." The NP (Nurse Practitioner) Coordination Note documents a verbal order for wound care was given to the Skilled Nurse on 09/20/2024. The ";Hospice IDG (Interdisciplinary) Comprehensive Assessment and Plan of Care Update Report" for meeting date 09/24//2024 and the ";Hospice IDG (Interdisciplinary) Comprehensive Assessment and Plan of Care Update Report" for meeting (Recertification Order) date 10/01/2024 lack documented evidence of the plan of care being reviewed and revised to address the patient's wound care needs and to include the wound care recommendations/verbal order on 09/20/2024. The clinical record lacks documented evidence of the IDG (Interdisciplinary) Plan of Care being reviewed and revised as frequently as the patients condition of requires. The Hospice Physician Order dated 10/10/2024 (Certification Period 07/14/2024 to 10/11/2024) documents the following wound care order: ";Using Clean technique, cleanse wound with Normal Saline or wound cleanser, apply a dab of medical honey, apply a piece of gauze to wound, apply barrier film to periwound, and cover with silicone foam dressing. Perform wound care biweekly or PRN (as needed). VNS nurses will perform wound care during weekly visit." The Hospice Recertification Plan of Care Update for Certification Period 10/12/2024 to 01/09/2025 lacks documentation of being updated with the current wound care order to the sacral area. On 10/15/2024 at 1:35PM an observational home visit was conducted with the Skilled Nurse/Registered Nurse. During the home visit, the Skilled Nurse was observed performing wound care on the sacral (coccyx) area. The Skilled Nurse was interviewed regarding the wound care order. The Skilled nurse stated, ";I was following wound care order dated 10/10/2024." The Skilled nurse showed the surveyor the wound care order dated 10/10/2024 in the patients electronic medical record. The Hospice Physician Order dated 10/16/2024 (Certification Period 10/12/2024 to 01/09/2025) was entered after the home visit and documents: ";Wound with Normal Saline or wound cleanser, apply a dab of medical honey, apply a gauze to wound, apply barrier film to periwound, and cover with silicone foam dressing. Perform wound care biweekly or PRN (as needed). VNS nurses will perform wound care during weekly visit." There is no documented evidence the Hospice IDG (Interdisciplinary Group) reviewing and revising the patients individualized plan of care to ensure current orders are included to address patients condition. On 10/17/2024 at 2:35pm, the Administrator, the Vice President of Quality, the Directors of Clinical Services/Directors of Patient Services, and staff were interviewed and did not provide an explanation for the survey findings. 2. Patient #3 has a Start of Care date of 09/01/2024 with diagnoses of Malignant Neoplasm of Colon Unspecified, Secondary Malignant Neoplasm of Retroperitoneum and Peritoneum, Constipation Unspecified, Chronic Embolism and Thrombosis of Unspecified Deep Veins of Unspecified Lower Extremity documented in the "Hospice Certification and Plan of Care" for Certification Period 09/01/2024 to 11/29/2024. The "Hospice Certification and Plan of Care" for Certification Period 09/01/2024 to 11/29/2024 documents the following medications: to treat nausea/vomiting - Ondansetron HCL (Hydrochloride) 4mg tablet, 1 tablet 3 times daily prn (as needed) and Hospice Comfort Pak: ";Prochlorperazine (Compazine) 10mg tablet, every 6 hours for nausea, vomiting; and to treat Deep Vein Thrombosis (DVT) – Eliquis (blood thinner) 5mg Tablet, 1 Tablet, every 12 hours. The Coordination Note – Triage RN (Registered Nurse) Call Note dated 10/06/2024 documents the following report of vomiting/symptom management: 10/6/2024 5:52:00PM - the patients primary caregiver ";called to report patient vomiting despite Ondansetron HCL(Hydrochloride) 4mg tablet. Per caller patient has vomited 6 times today. Caller placed on hold to contact NP (Nurse Practitioner);" 10/6/2024 5:56:00PM – Nurse Practitioner said patient ";to take Compazine now and at 10PM then every 4 hours thereafter as needed;" 10/6/2024 5:56:00PM – ";Triage RN (Registered Nurse) relayed NP (Nurse Practitioner) orders to give Compazine (Prochlorperazine) now, at 10PM, and every 4 hours if needed;" and 10/6/2024 6:49:00PM – Outbound call to patients primary caregiver ";to check in on symptoms since taking Compazine. Symptoms have improved and patient is sleeping." The clinical record lacks documented evidence of an order for Compazine (Prochlorperazine) Every 4 Hours as needed. The Comfort Pak order is ";Prochlorperazine (Compazine) 10mg tablet every 6 hours for nausea, vomiting." The ";Hospice IDG (Interdisciplinary) Comprehensive Assessment and Plan of Care Update Report" for meeting date 10/08/2024 lacks documented evidence of the plan of care being reviewed and revised with the order to administer Compazine (Prochlorperazine) 4mg Every 4 hours as needed for vomiting. The Coordination Note – Triage RN (Registered Nurse) Call Note dated 10/08/2024 documents another report of vomiting and symptom management: 10/08/2024 2:15:00AM – Patients primary caregiver called to report patient ";has vomited blood three times. (Primary caregiver) gave Ondansetron 4mg at 2135 (9:35PM). (Primary caregiver) is requesting a nurse visit to assess (patient)." The Coordination Note – Missed Visit Notification dated 10/08/2024 documents: the patients primary caregiver ";request to reschedule AHN (After Hour Nurse) visit for the daytime when patient wakes up. PCG (Primary caregiver) verbalized patient is sleeping comfortably and requesting to allow patient to sleep. PCG (Primary caregiver) requesting AM (morning) daytime visit today to evaluate patient vomiting blood tinged drainage. Nurse collaborated with HMD (Hospice Medical Doctor). HMD (Hospice Medical Doctor) ordered the following: Hold Eliquis (blood thinner). Team to follow up with the continued need for Eliquis. PCG (Primary Caregiver) instructed on the same." The Skilled Nurse/Licensed Practical Nurse ";Visit Note Report" dated 10/08/2024 (11:14AM In-Home Began Time) documents: ";Patient is breathing comfortably on room air with no signs of discomfort noted. Patient complains of episodes of blood in sputum overnight. Covering MD (Medical Doctor) contacted by this nurse. Caregiver advised to continue holding blood thinner for 48 hours. Caregiver express understanding of the same." The ";Hospice IDG (Interdisciplinary) Comprehensive Assessment and Plan of Care Update Report" for meeting date 10/08/2024 lacks documented evidence of the hospice plan of care being reviewed and revised to include orders to hold Eliquis for 48 hours and to reevaluate patients response after 48 hours. The Interdisciplinary Plan of Care" Policy (Revised May 2020) documents: ";The hospice IDG (Interdisciplinary Group) (in collaboration with the individuals attending physician, if any) reviews, revises and documents the individualized plan as frequently as the patients condition requires, but no less frequently than every 15 calendar days." The clinical record lacks documented evidence of the IDG (Interdisciplinary) Plan of Care being reviewed and revised as frequently as the patients condition of requires in accordance with the Interdisciplinary Plan of Care" Policy. On 10/17/2024 at 2:35pm, the Administrator, the Vice President of Quality, the Directors of Clinical Services/Directors of Patient Services, and staff were interviewed and did not provide an explanation for the survey findings. 3. Patient #6 has a Start of Care date of 01/08/2024 with diagnosis of Alzheimers Disease documented in the Hospice Certification of Terminal Illness for the Certification Period 09/04/2024 to 11/02/2024. The Hospice Recertification Plan of Care Update for the Certification Period 04/07/2024 to 07/05/2024 documents the following wound care orders: ";Hospice nurse to perform the following wound care (to) Stage 3 Pressure Injury of the Sacrum utilizing clean technique – Cleanse with wound cleanser. Apply Hydrofiber/Aquacel, cover with composite foam dressing, and change 2 times/week and PRN (as needed). Instruct caregiver (name) in (wound) care. Caregiver will provide wound care 1 times/week between nurse visits and PRN (as needed)." The Skilled Nurse/Registered Nurse ";Visit Note Report" dated 06/06/2024 documents: Sacral Pressure Ulcer Stage 3 – Change in Status ";wound resolved (healed)." The Hospice IDG Comprehensive Assessment and Plan of Care Update Report(s) for meeting date 06/18/2024 and 06/25/2024 (Recertification) document: ";healed wounds on sacrum." The Hospice Recertification Plan of Care Update(s) Order Date 06/14/2024 for Certification Period 07/06/2024 to 09/03/2024 and 08/20/2024 Order for Certification period 09/04/2024 to 11/02/2024 continue to document wound care orders for Stage 3 Pressure Injury of sacrum. The IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report(s) lack documented evidence of the Interdisciplinary Group reviewing and revising the hospice plan of care to discontinue wound care order to the sacrum. On 10/21/2024 at 12:15pm, the Administrator, the Vice President of Quality, the Director of Clinical Services/Director of Patient Services, and staff were interviewed and did not provide an explanation for the survey findings.

Based on clinical care record reviews and staff interviews, the agency failed to ensure adequate supervision of the nursing services. This was evident for one (1) of thirty (30) clinical records reviewed. (Patients #3). Failure to ensure that adequate supervision of the nursing services, has the potential for negative patient outcomes. The Findings Are: --- 1. Patient #3 has a Start of Care date of 09/01/2024 with diagnoses of Malignant Neoplasm of Colon Unspecified, Secondary Malignant Neoplasm of Retroperitoneum and Peritoneum, Constipation Unspecified, Chronic Embolism and Thrombosis of Unspecified Deep Veins of Unspecified Lower Extremity documented in the "Hospice Certification and Plan of Care" for Certification Period 09/01/2024 to 11/29/2024. The Skilled Nurse/Registered Nurse ";Visit Note Report" dated 10/02/2024 documents: respiratory assessment findings - ";no abnormal respiratory findings identified." The Skilled Nurse/Licensed Practical Nurse ";Visit Note Report" dated 10/08/2024 documents: respiratory assessment findings - ";use of accessory muscles." The clinical record lacks documented evidence of the Licensed Practical Nurse reporting the respiratory findings and the Registered Nurse reviewing the Licensed Practical Nurse 's findings to ensure the provision of appropriate care. On 10/17/2024 at 2:35PM the Administrators/the Directors of Clinical Services/Directors of Patient Services, (Senior Vice President Hospice and Palliative Care, Vice President Clinical Operations) and staff were interviewed and did not provide an explanation for the survey finding.

Based on clinical record reviews and staff interview, the hospice failed to ensure all Hospice Aides receive complete written patient care instructions. This was evident for nine (9) of thirty (30) clinical records reviewed. (Patients #1, #7, #10, #11, #12, #16, #17, #22, and #25). Failure to ensure all Hospice Aides receive complete written patient care instructions, has the potential for negative patient outcomes. The Findings Are: --- *. Patient #22 has a Start of Care date 9/06/2024 with a diagnosis of Malignant Neoplasm of Prostate documented on the Hospice Certification and Plan of Care with a Certification Period from 9/06/2024 to 12/04/2024. The Hospice Certification and Plan of Care with a Certification Period from 9/06/2024 to 12/04/2024 documents: ";Hospice Nurse to insert/maintain indwelling catheter ... change catheter as needed for infection, obstruction or when the closed system is compromised. Hospice Nurse to coordinate Plan of Care with facility staff." The Client Episode Coordination Note Report dated 9/20/2024 documents: ";Call Note: Caller: Name (son). Request: to confirm POC (Plan of Care) for pt (patient). Call Note: states that HHA (Home Health Aide) did not want to take pt (patient) out or change catheter bag – Please call back." The Hospice Home Health Aide Plan of Care from 9/06/2024 to 12/04/2024 lacks documented evidence of the instructions for the aide to change the catheter bag and aide observations that should be reported to the supervisor. There is no documented evidence of an accurate written patient care instructions for a hospice aide to follow. On 10/17/2024 at 02:35pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. *Patient #16 has a Start of Care date of 09/06/2024 with the following diagnoses "Other Sequelae of Cerebral Infarction, Essential (Primary) Hypertension, Depression" documented on the Hospice Recertification Plan of Care Update for the Certification Period 09/06/2024 to 12/04/2024. The Hospice Recertification Plan of Care Update for the Certification Period 09/06/2024 to 12/04/2024 documents: "HHA (home health aide) effective 09/08/2024 5 WK 12 (five times a week for twelve weeks), 3 WK 1(three times per week for one week); DME (durable medical equipment) and Supplies: O2 (oxygen) Home Setups; Safety Measures: O2 Precautions, Fall Precautions; Nutritional Requirements: Pureed, Thin Liquid, Comfort Feeding". The Aide Plan of Care Report dated 09/06/2024 lacks documented evidence of DME (durable medical equipment) and Supplies - O2 (oxygen) home, Safety Measures - O2 (oxygen) Precautions for oxygen, Fall Precautions and Nutritional Requirements/diet. There is no documented evidence of a complete Aide's Plan of Care. On 10/18/2024 at 02:35pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. *Patient #17 has a Start of Care date of 07/03/2024 with the following diagnoses "Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Gastro-Esophageal Reflux Disease" documented on the Hospice Recertification Plan of Care Update for the Certification Period 10/01/2024 to 12/29/2024. The Hospice Recertification Plan of Care Update for the Certification Period 10/01/2024 to 12/29/2024 documents: "HHA (home health aide) effective 10/01/2024 4 WK 1(four times per week for one week), 6 WK 12 (six times per week for twelve weeks), 1 WK 1(once a week for one week); Medications: Current O2-Oxygen Start Date: 07/05/2024" The Aide Plan of Care Report dated 10/01/2024 lacks documented evidence of DME (durable medical equipment) and Supplies - O2 (oxygen) home, Safety Measures - O2 (oxygen) Precautions for oxygen use and diet. There is no documented evidence of a complete Aide's Plan of Care. On 10/18/2024 at 02:35pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. *. Patient #7 has a Start of Care date of 08/22/2024 with the following diagnosis "Diffuse Large B-Cell Lymphoma" documented in the Hospice Certification and Plan of Care for the Certification Period 08/22/2024 to 11/19/2024. The Hospice Certification and Plan of Care for the Certification Period 08/22/2024 to 11/19/2024 documents: hha (home health aide) effective 08/25/2024 1WK12 (once a week for twelve weeks); DME (durable medical equipment): wheelchair. The Visit Note Report dated 08/22/2024 documents: Existing equipment / supplies owned by patient: cane, walker, shower stool. The Aide Plan of Care Report dated 08/22/2024 lacks documented evidence of the diet; DME (durable medical equipment) – wheelchair, walker, cane, shower stool; and instructions of aide observations that should be reported to the supervisor. There is no documented evidence of an accurate written patient care instructions for a hospice aide to follow. On 10/17/2024 at 02:35pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. *. Patient #10 has a Start of Care date of 09/03/2024 with the following diagnoses "Alzheimers Disease, Dementia" documented in the Hospice Certification of Terminal Illness for the Certification Period 09/03/2024 to 12/01/2024. The Hospice Certification of Terminal Illness for the Certification Period 09/03/2024 to 12/01/2024 documents: hha (home health aide) 1WK1, 3WK12 (once a week for one week, three times a week for twelve weeks), Nutritional Requirements: soft thin liquids. The Visit Note Report dated 09/03/2024 documents: Existing equipment / supplies owned by patient: hospital bed, walker. The Aide Plan of Care Report dated 09/03/2024 lacks documented evidence of the diet; DME (durable medical equipment) – hospital bed, walker; and instructions of aide observations that should be reported to the supervisor. There is no documented evidence of an accurate written patient care instructions for a hospice aide to follow. On 10/17/2024 at 02:35pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. *. Patient #11 has a Start of Care date of 09/09/2024 with the following diagnoses "Malignant Neoplasm of Ovary, Anxiety Disorder" documented in the Hospice Certification and Plan of Care for the Certification Period 09/09/2024 to 12/07/2024. The Hospice Certification and Plan of Care for the Certification Period 09/09/2024 to 12/07/2024 documents: hha (home health aide) 4WK1, 5WK12 (four times a week for one week, five times a week for twelve weeks), Allergies: Shellfish, Dermabond, Doxycycline, Tetracycline. The Aide Plan of Care Report dated 09/09/2024 lacks documented evidence of the allergies and instructions of aide observations that should be reported to the supervisor. There is no documented evidence of an accurate written patient care instructions for a hospice aide to follow. On 10/18/2024 at 03:00pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. *. Patient #12 has a Start of Care date of 04/05/2024 with the following diagnosis "Senile Degeneration of Brain" documented in the Hospice Certification of Terminal Illness for the Certification Period 07/04/2024 to 10/01/2024. The Hospice Recertification Plan of Care Update for the Certification Period 07/04/2024 to 10/01/2024 documents: hha (home health aide) frequency 5days x 2hours, DME (durable medical equipment) – hospital bed. The Visit Note Report (Recertification Assessment) dated 06/14/2024 documents: Pt (patient) requires Hoyer Lift with 2 persons assist daily, shes OOB (out of bed) to Geri chair daily as tolerated. The Aide Plan of Care Report dated 07/04/2024 lacks documented evidence of the DME (durable medical equipment): Hoyer Lift and Gerichair; and instructions of aide observations that should be reported to the supervisor. There is no documented evidence of an accurate written patient care instructions for a hospice aide to follow. On 10/18/2024 at 03:00pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. *. Patient #25 has a Start of Care date of 01/09/2024 and a discharge date of 01/30/2024 with the following diagnoses "Heart Failure, Vascular Dementia" documented in the Hospice Certification and Plan of Care for the Certification Period 01/09/2024 to 04/07/2024. The Hospice Certification and Plan of Care for the Certification Period 01/09/2024 to 04/07/2024 documents: hha (home health aide) 2WK1, 5WK12 (twice a week for one week, five times a week for twelve weeks; Allergies: Sulfa. The Aide Plan of Care Report dated 01/12/2024 lacks documented evidence of the allergies and instructions of aide observations that should be reported to the supervisor. There is no documented evidence of an accurate written patient care instructions for a hospice aide to follow. On 10/18/2024 at 03:00pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. 1. Patient #1 has a Start of Care date of 07/14/2024 with diagnosis of Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung documented in the "Hospice Certification and Plan of Care" for Certification Period 07/14/2024 to 10/11/2024. The "Hospice Certification and Plan of Care" for Certification Period 07/14/2024 to 10/11/2024 documents: ";Home Health Aide service for assistance with personal care, hygiene and activities of daily living. (Home Health Aide) frequency 5Daysx2Hours (five days a week times two hours a day), Monday-Friday." The Coordination note dated 07/15/2024 documents: ";TC (Telephone call) on 7/15/24 @ 5:32pm with pts (patients) (spouse) informing (spouse) that pts (patients) SOC (aide start of care) is effective as of 7/16/24-7/17/24, Mon-Fri, 2 hours. Pts (Patients) (spouse) requested aide to come in between 8-10 or 9-11am. Let (spouse) know that (home health aide) is scheduled for Wed 7/17/24 from 9-11;" ";(spouse) requested to cancel services for 7/16/24 but resume for 7/17/24 instead." The Coordination Note dated 07/17/2024 documents: ";Time of Call: 7/17/2024 9:47AM;" ";Pt (Patient) spouse stated the aide is refusing to assist with pt (patient) until (aide) obtains a POC (plan of care). (Patients spouse) also stated no nurse has come out as yet;" ";Action Taken: T/C (Telephone call) placed to the nurse (name). As per (nurse), (nurse) will be there between 11-11:30am. (Spouse) was informed & agreed." The Skilled Nurse/Registered Nurse ";Visit Note Report" dated 07/17/2024 documents the following the supervision of the aide: ";Were supervisory functions performed? No;" and ";Indicate Other reason supervisory function not performed: (Home Health Aide) ended shift." There is no documented evidence of the registered nurse providing written patient care instructions (aide plan of care) for the Home Health Aide (Hospice Aide) at the start of aide services. On 10/17/2024 at 2:35pm, the Administrator, the Vice President of Quality, the Directors of Clinical Services/Directors of Patient Services, and staff were interviewed and did not provide an explanation for the survey finding.

Based on clinical record review and staff interview, the hospice failed to ensure hospice aide supervisory visits are conducted every 14 days. This was evident for four (4) of thirty (30) clinical records reviewed. (Patients #1, #7, #14, and #25). Failure to ensure hospice aide supervisory visits are conducted every 14 days, has the potential for negative patient outcomes. The Findings Are: --- 4. Patient #14 has a Start of Care date of 10/27/2023 with the following diagnoses "Malignant Neoplasm of Prostate, Vascular Dementia, Dysphagia" documented on the Hospice Recertification Plan of Care Update for the Certification Period 08/22/2024 to 10/20/2024. The Hospice Recertification Plan of Care Update for the Certification Period 08/22/2024 to 10/20/2024 documents: "HHA (home health aide) effective 08/25/2024 5 WK 8 (five times per week for eight weeks). The Duty Sheet by Visit Date documents aide services being provided from 09/26/2024 to 10/17/2024. The clinical record lacks documented evidence of home health aide supervision from 09/26/2024 to 10/15/2024. (greater than 14 days) The clinical record lacks documented evidence of home health aide supervision every (14) fourteen days. On 10/17/2024 at 02:35 pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. 2. Patient #7 has a Start of Care date of 08/22/2024 with the following diagnosis "Diffuse Large B-Cell Lymphoma" documented in the Hospice Certification and Plan of Care for the Certification Period 08/22/2024 to 11/19/2024. The Hospice Certification and Plan of Care for the Certification Period 08/22/2024 to 11/19/2024 documents: hha (home health aide) effective 08/25/2024 1WK12 (once a week for twelve weeks). The Visit Calendar documents aide services being provided on 09/12/2024, 09/19/2024, 09/26/2024, 10/03/2024, and 10/10/2024. The clinical record documents aide supervision completed on 09/12/2024, and 10/04/2024. The clinical record lacks documented evidence of aide supervision every 14 days. On 10/17/2024 at 02:35pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. 3. Patient #25 has a Start of Care date of 01/09/2024 and a discharge date of 01/30/2024 with the following diagnoses "Heart Failure, Vascular Dementia" documented in the Hospice Certification and Plan of Care for the Certification Period 01/09/2024 to 04/07/2024. The Hospice Certification and Plan of Care for the Certification Period 01/09/2024 to 04/07/2024 documents: hha (home health aide) 2WK1, 5WK12 (twice a week for one week, five times a week for twelve weeks; Allergies: Sulfa. The Duty Sheet by Visit Date documents aide services being provided on 01/20/2024, 01/27/2024, and 01/28/2024. The clinical record lacks documented evidence of aide supervision. On 10/18/2024 at 03:00pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. 1. Patient #1 has a Start of Care date of 07/14/2024 with diagnosis of Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung documented in the "Hospice Certification and Plan of Care" for Certification Period 07/14/2024 to 10/11/2024. The "Hospice Certification and Plan of Care" for Certification Period 07/14/2024 to 10/11/2024 documents: "Home Health Aide service for assistance with personal care, hygiene and activities of daily living. (Home Health Aide) frequency 5Daysx2Hours (five days a week times two hours a day), Monday-Friday." The Coordination note dated 07/15/2024 documents: ";TC (Telephone call) on 7/15/24 @ 5:32pm with pts (patients) (spouse) informing (spouse) that pts (patients) SOC (aide start of care) is effective as of 7/16/24-7/17/24, Mon-Fri, 2 hours. Pts (Patients) (spouse) requested aide to come in between 8-10 or 9-11am. Let (spouse) know that (home health aide) is scheduled for Wed 7/17/24 from 9-11." The Coordination Note dated 07/17/2024 documents: ";Time of Call: 7/17/2024 9:47AM;" ";Pt (Patient) spouse stated the aide is refusing to assist with pt (patient) until (aide) obtains a POC (plan of care). (Patients spouse) also stated no nurse has come out as yet;" ";Action Taken: T/C (Telephone call) placed to the nurse (name). As per (nurse), (nurse) will be there between 11-11:30am. (Spouse) was informed & agreed." The Skilled Nurse/Registered Nurse ";Visit Note Report" dated 07/17/2024 documents the following response to the supervision of the aide: ";Were supervisory functions performed? NO;" ";Indicate other reason supervisory functions not performed: (Home Health Aide) has already ended shift." There is no documented evidence of the registered nurse ensuring the home health aide (hospice aide) are adequately supervised, and that hospice aide furnished care to meet the patients needs at the start of aide services. On 10/17/2024 at 2:35pm, the Administrator, the Vice President of Quality, the Directors of Clinical Services/Directors of Patient Services, and staff were interviewed and did not provide an explanation for the survey finding.

Based on clinical record reviews and staff interviews, the hospice failed to ensure that Nursing services are provided according to the plan of care. This was evident for one (1) of four (4) clinical records reviewed (Patient #1). Failure to provide services according to the plan of care has the potential for negative patient outcomes. The findings are: --- 1. Patient #1 has Start of Care date of 4/25/2024 and a discharge date of 04/28/2024, with the following diagnoses of ";Alzheimers disease, Dysphagia, Acute Kidney Failure, Pressure Ulcer of Right Buttock, Stage 1, and Pressure Ulcer of Left Buttock, Stage 1," documented on the Hospice Certification and Plan of Care with a certification period from 4/25/24 to 7/23/24. The Hospice Certification and Plan of Care (medical orders) with a Certification Period from 4/25/24 to 7/23/24 documents orders for ";SN 2WK1, 1WK13, 6PRN for Symptom Management," (Skilled Nursing two times a week for one week, then one times a week for 13 weeks, and six as needed for symptom management). The Hospices work week is Sunday through Saturday. The clinical record documents the Hospice RN (Registered Nurse) conducting an initial nursing visit on 4/25/24 during the first work week from Sunday, 4/21/24 to Saturday, 4/27/24. There is no documented evidence of a second nursing visit during the first work week from Sunday, 4/21/24 to Saturday, 4/27/24, as ordered. On 8/16/24 at 1:00 pm, the Vice President of Clinical Operations and Vice President Quality were interviewed and did not provide an explanation for the findings.

Based on clinical record reviews and staff interviews, the hospice licensed professionals failed to coordinate all aspects of the patients hospice care with the patients family. This was evident for one (1) of four (4) clinical records reviewed (Patient #1). Failure to coordinate all aspects of a patients care with the patients family has the potential for negative patient outcomes. The findings are: --- 1. Patient #1 has Start of Care date of 4/25/2024 and a discharge date of 04/28/2024, with the following diagnoses of ";Alzheimers disease, Dysphagia, Acute Kidney Failure, Pressure Ulcer of Right Buttock, Stage 1, and Pressure Ulcer of Left Buttock, Stage 1," documented on the Hospice Certification and Plan of Care with a certification period from 4/25/24 to 7/23/24. The "Hospice -Liaison Daily Update" note dated 4/25/24 documents, ";Email received from PTS HCP (patients Health Care Proxy) (name of health care proxy) regarding a missed call from the ARN (Admitting Registered Nurse) and follow up care of PT (patient). I referred this to (name of Hospice employee) and Admission Registered Nurse to follow up with Health Care Proxy." There is no documented evidence of the Admitting RN following up with health care proxy about the patients care. The ";Hospice- CCC/AH (Customer Call Center/After Hours) Urgent Clinical (ASAP F/UP Needed)," (As Soon As Possible Follow UP Needed) note dated 4/27/24 documents, ";Note: Call Start Time: 4/27/24, 4:20 pm. Caller Name (name of Health Care Proxy) . . . . . Request: patient inquiry. Call Notes nurse was here on Thursday to evaluate the patient. Caller wants to know when services is going to start. Action Taken: message conveyed to team . . . . "; There is no documented evidence of the hospice returning the health care proxys phone call requesting to find out about the start of the patients hospice services. On 8/16/24 at 11:30 am, the Vice President of Clinical Operations and Vice President Quality were interviewed. The Vice President of Clinical Operations stated, ";We found out the call center (representative) who escalated the call closed the call so it never got to a supervisor. "; The Vice President of Quality stated, ";We interviewed the nurse and she does not have anything (follow up email or call to the health care proxy)."

Based on clinical care record review and staff interviews, the governing authority failed to ensure nursing needs of the patient are met as identified in the assessments. This was evident for one (1) of three (3) patient care records reviewed (Patient #1). Failure to ensure nursing needs of the patient are met as identified in the assessments has the potential for negative patient outcomes. The findings are: --- The NPIAP (National Pressure Injury Advisory Panel) Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Guidelines for 2019 documents: Pressure injuries are painful. Individuals with pressure injuries experience wound-related pain that can be quantified and differentiated from other pain, and this pain occurs both during procedures and at rest. 1. Patient #1 has a Start of Care date of 12/14/2023 and a discharge date (expired) of 12/26/2023, with the following diagnoses "Alzheimers Disease, Dementia, Dysphagia" documented in the Hospice Certification and Plan of Care dated 12/14/2023 to 03/12/2024. The Hospice Certification and Plan of Care dated 12/14/2023 to 03/12/2024 documents: Pressure Ulcers on Right Buttock at Stage III, Left Buttocks at Stage III, and Right Heel DTI (deep tissue injury). Medication: Acetaminophen 325 mg (milligram) 2 tablet every 6 hours PRN (as needed). Goals: Wound will be managed without infection and pain will be controlled. The Visit Note Report dated 12/14/2023 documents: Patients Mental Status: Disoriented, confused, lethargic; Type of standardized pain tool used: Staff observation; Indicate what makes pain worse: procedures or treatments; Communicate a choice: Patient cannot make a choice and provides no logical reasoning; minimally verbal. The clinical record documents hospice nurse assessment on 12/14/2023, 12/15/2023, and 12/20/2023 patient have no pain and wound care was done by facility nurse. There is no documented evidence of the pain assessment during dressing change. There is no documented evidence of a complete assessment to ensure that the needs of the patient are met. On 06/14/2024 at 3:09pm, the Vice President was interviewed and did not provide an explanation for the findings.

Based on clinical care record review and staff interviews, the governing authority failed to ensure that the supervising nurse must assess an aides ability to demonstrate initial satisfactory performance. This was evident for one (1) of three (3) patient care records reviewed (Patient #1). Failure to ensure that the supervising nurse must assess an aides ability to demonstrate initial satisfactory performance has the potential for negative patient outcomes. The findings are: --- 1. Patient #1 has a Start of Care date of 12/14/2023 and a discharge date (expired) of 12/26/2023,with the following diagnoses "Alzheimers Disease, Dementia, Dysphagia" documented in the Hospice Certification and Plan of Care dated 12/14/2023 to 03/12/2024. The Hospice Certification and Plan of Care dated 12/14/2023 to 03/12/2024 documents: ";hha (home health aide) 1WK1, 5WK12 (once a week for one week, five times a week for twelve weeks)." The Aide Duty Sheet documents aide providing services on 12/15/2023, 12/18/2023 to 12/22/2023, and 12/25/2023. There is no documented evidence of an initial nursing supervision to assess an aides ability and satisfactory performance. On 06/14/2024 at 3:09pm, the Vice President was interviewed and did not provide an explanation for the findings.

Based on clinical care record review and staff interviews, the governing authority failed to ensure a physician order. This was evident for one (1) of three (3) patient care records reviewed (Patient #1). Failure to ensure a physician order has the potential for negative patient outcomes. The findings are: --- 1. Patient #1 has a Start of Care date of 12/14/2023 and a discharge date (expired) of 12/26/2023, with the following diagnoses "Alzheimers Disease, Dementia, Dysphagia" documented in the Hospice Certification and Plan of Care dated 12/14/2023 to 03/12/2024. The Hospice Certification and Plan of Care dated 12/14/2023 to 03/12/2024 documents: Nutritional Requirements: Puree diet, thin liquids. The Client Episode Coordination Notes Report dated 12/20/2023 documents: ";RN (registered nurse) collaborate with facility (name of physician) on patient coughing while eating. She ordered speech and swallow test and changes to patients diet." The Order Listing (from the nursing home) printed on 06/14/2024 documents: Regular diet, puree level 4 texture. Moderate Thick (formerly Nectar) Level 3 consistency (liquids), start date 12/20/2023. There is no documented evidence of the physician order on the changed of diet. On 06/14/2024 at 3:30pm, the Vice President and the Assistant Vice President were interviewed and did not provide an explanation for the findings.

Based on clinical care record review and staff interviews, the governing authority failed to ensure that the SNF (skilled nursing facility) immediately notifies the hospice that suggest a need to alter the plan of care. This was evident for one (1) of three (3) patient care records reviewed (Patient #1). Failure to ensure that SNF (skilled nursing facility) immediately notifies the hospice that suggest a need to alter the plan of care has the potential for negative patient outcomes. The findings are: --- 1. Patient #1 has a Start of Care date of 12/14/2023 and a discharge date (expired) of 12/26/2023, with the following diagnoses "Alzheimers Disease, Dementia, Dysphagia" documented in the Hospice Certification and Plan of Care dated 12/14/2023 to 03/12/2024. The Hospice Certification and Plan of Care dated 12/14/2023 to 03/12/2024 documents: ";Nutritional Requirements: Puree diet, thin liquids." The Aide Care Plan Report dated 12/14/2023 documents: ";ADL (activities of daily living) services: Feed patient five times a week; Pureed/ thin liquids." The Order Listing (from the nursing home) printed on 06/14/2024 documents: Ceftriaxone Sodium Solution, use 1 gram intravenously every 24 hours for pneumonia for 5 days, start date 12/24/2023.Regular diet, puree level 4 texture. Moderate Thick (formerly Nectar) Level 3 consistency (liquids), start date 12/20/2023. There is no documented evidence of the SNF (skilled nursing facility) immediately notifying the hospice of the diet change and new diagnosis of pneumonia – placed on intravenous antibiotic, to alter the hospice plan of care and aides instructions. On 06/14/2024 at 3:09pm, the Vice President was interviewed and did not provide an explanation for the findings.

Based on clinical care record review and staff interviews, the Hospice failed to ensure that medical supplies, appliances, and durable medical equipment must be provided by the hospice. This was evident for one (1) of three (3) patient care records reviewed (Patient #1). Failure to ensure that medical supplies, appliances, and durable medical equipment must be provided by the hospice has the potential for negative patient outcomes. The findings are: --- The Hospice Recertification Plan of Care dated 06/27/2022 to 08/25/2022 documents: "SN 06/27/2022 1 wk 9 (one time per week for nine weeks), 4 (four visits) PRN (as needed) for symptom management". The SN Client Episode Coordination Notes Report dated 06/23/2022 documents:" Updated wound care picture of sacrum area provided to WOCN NP WOCN (Wound Ostomy and Continence Nurse) Consult with daughter permission. Recommendation to cleanse with wound cleanser and apply a DAB of Therahoney BIW (twice a week) and cover with Optifoam dressing. Daughter made aware and is in agreement with treatment plan. Wound care supply ordered reinforced turning and repositioning every 2 hours to avoid further skin breakdown. And understanding verbalized by daughter. Hospice available 24/7 reinforced. Collaborated with HTM(hospice team manager) RN regarding todays visit" The Hospice Physician Order dated 07/06/2022 documents: " Hospice nurse to performe wound care weekly to stage 3 upper buttock. Utilizing clean technique clean with wound cleanser, pat dry, apply Medihoney, apply Zinc to peri wound and secure with Optifoam, change 2-3 times per week and PRN. Instruct caregiver in wound care. Caregiver will verbalize/demonstrate appropriate and safe wound care to perform when nurse is unable to perform." The RN visit dated 07/06/2022 documents Wound care to buttock and sacral area performed. No signs and symptoms of infection noted." The RN visit dated 07/14/2022 documents:" Wound care provided and tolerated." The RN visit dated 07/20/2022 documents:" Wound care provided and tolerated." The RN visit dated 07/28/2022 documentsP:"Sacral wound continues to heal without infection. Daughter provides wound care when nurse is not present." The SN Visit Notes dated 07/06/2022, 07/14/2022, 07/20/2022, 07/28/2022 included wound measurements and wounds assessments of the sacral area and upper buttock. 07/09/2022 wound care supply delivered.(Silicon Faced Foam and Border Sacrum Dressing - 10, and Adhesive Foam Dressing 1) 07/29/2022 wound care supply delivered. (Sterile Border Gauze Pad/Stratasorb Dressing - 6). There is no documented evidence of the RN ordering enough wound care (Optifoam) supply since 07/09/2022 to 07/29/2022. (for two wounds: sacral area and upper buttock.) On 09/09/2022 at 1:30 pm, the Director of Quality was interviewed and did not provide an explanation for the survey findings.

Based on clinical record review and interview, the hospice failed to conduct and document a patient specific comprehensive assessment that identifies the wound care needs of the patient. The hospice failed to: Ensure the content of the comprehensive assessment was of sufficient scope to identify all the patient's wound care needs in order to promote the patient's well-being and comfort throughout the patient's dying process for one (1) of three (3) patients with wounds (refer to L524). Ensure hospice nurses and Interdisciplinary Group (IDG) members are performing complete updated comprehensive assessments or that the hospice nurses are communicating changes in the patient wound care needs and condition to the IDG for one (1) of three (3) patients with wounds (refer to L533). The cumulative effect of the systemic issues identified in the agency's failure to ensure initial and comprehensive assessments are completed has the potential for negative patient outcomes, and resulted in the likelihood of patient harm for Patients #1.

Based on clinical record review, hospice policy and procedures, and staff interviews, the hospice failed to ensure the content of the comprehensive assessment is of sufficient scope to identify all of the patient's wound care needs in order to develop a comprehensive Plan of Care the patient and family. This was evident for one (1) of three (3) clinical records reviewed of patients with wounds (Patient #1). Failure to conduct a comprehensive assessment of the patient has the potential for the development of an incomplete Plan of Care, unmet patient needs and the likelihood of patient harm. The findings are: The Hospice "Initial and Comprehensive Assessment" Policy documents: "Comprehensive assessment means a thorough evaluation of the patient's physical, psychosocial, emotional and spiritual status related to the terminal illness and related conditions. This includes a thorough evaluation of the caregiver's and family's willingness and capability to care for the patient;" "The comprehensive lan of care for the patient and family is developed and documented with the comprehensive assessment." 1. Patient #1 has a Start of Care date (SOC) of 04/20/2022 with diagnoses of "Cerebral Atherosclerosis, Peripheral Vascular Angioplasty Status, Pressure Ulcer of Other Site Unstageable, Pressure Ulcer of Right Heel Unstageable, Type 2 Diabetes Mellitus With Other Specified Complication and Chronic Kidney Disease, Stage 4 (Severe)" documented in the "Hospice Certification and Plan of Care" dated 04/20/2022 to 07/18/2022. The hospital referral record fax dated 04/18/2022 documents: "Skin: dry gangrene of wound on right foot;" "Pt (Patient) has 2 pressure ulcer(s) on the right leg;" "Pressure Ulcers on Legs: Pt has three ulcers; most severe is on right leg." The "Hospice Certification and Plan of Care" dated 04/20/2022 to 07/18/2022 documents: SN (Skilled Nurse) visit frequency, "2WK1 (two visits a week for one week), 1WK13 (one visit a week for 13 weeks), 4 PRN (four as need visits) for symptom management;" "Hospice Nurse to perform the following wound care to (unstageable wound of Rt (Right) Lateral Calf and Heel). Utilizing clean technique;" "Caregiver will provide wound care 4-5 times/week between nurse visits and PRN. Pt's son (name) manages wound care. Team to F/U (follow-up) with wound care orders/assessment." The "RN (Registered Nurse) Hospice Admission" comprehensive assessment dated 04/20/2022 documents: "Is the wound(s) assessment documentation in the integumentary command center (ICC)? YES:" ICC Wound Assessment: "Wound assessment: Rt Dist (distal) Calf, Rt, Unstage: Wound assessed- NO. Caregiver completed care; Rt Heel, Rt Unstage - Wound assessed- NO. Caregiver completed care;" "Narrative: Pt has two unspecified wounds on her Rt lateral calf and Rt heel. Wound care had just been completed prior to visit so dressing could not be removed as HHA (non-hospice home health aide) was new and did not know location of wound supplies. She stated that pt's son provided wound care early in the morning." The RN comprehensive assessment lacks documented evidence of the RN performing a wound assessment at the start of care. The RN comprehensive assessment lacks documentation of reflecting a complete and accurate picture of the patient's current integument/skin and wound status to assist in developing the patient's individualized hospice plan of care. The "Hospice IDG Comprehensive Assessment and Plan of Care Report" dated 4/26/2022, completed after the RN admission assessment, lacks documented evidence of the presence and locations of wounds including gangrene on the right foot. The IDG Plan of Care lacks documented evidence of wound care for gangrene on the right foot being addressed. On 7/20/2022 at 11:05AM, the Clinical Director, and the RN who conducted the initial assessment were interviewed. The RN stated, "I was unable to see the wounds;" "the (non-hospice) aide told me the patient's son did the wound care;" "I'm not sure" if gangrene was present;" "I did not have a conversation with the son" about wound care."

Based on clinical record reviews, policy and procedures review, and staff interviews, the Hospice failed to ensure the hospice nurses and Interdisciplinary Group (IDG) members are performing complete and updated comprehensive assessments, that the hospice nurses are communicating changes in the patient's condition that are consistent with the comprehensive assessment findings to the IDG. The was evident of one (1) of three (3) patients with wounds (Patient #1). Failure to ensure that comprehensive assessments are updated and reflect changes in the status of the patient has the potential for the patient's health status to be compromised and result in the provision of poor quality of care. The findings are: The Hospice "Initial and Comprehensive Assessment" Policy documents: "The update of the comprehensive assessment is accomplished by the hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) and considers changes that have taken place since the start-of-care comprehensive assessment;" "The plan of care (POC) for the patient and family is informed by the updated comprehensive assessment (UCA). The POC is updated as frequently as the condition of the patient requires but no less frequently than every 15 days" 1. Patient #1 has a Start of Care date (SOC) of 04/20/2022 with diagnoses of "Cerebral Atherosclerosis, Peripheral Vascular Angioplasty Status, Pressure Ulcer of Other Site Unstageable, Pressure Ulcer of Right Heel Unstageable, Type 2 Diabetes Mellitus With Other Specified Complication and Chronic Kidney Disease, Stage 4 (Severe)" documented in the "Hospice Certification and Plan of Care" dated 04/20/2022 to 07/18/2022. The "Hospice Certification and Plan of Care" dated 04/20/2022 to 07/18/2022 documents: SN (Skilled Nurse) visit frequency, "2WK1 (two visits a week for one week), 1WK13 (one visit a week for 13 weeks), 4 PRN (four as needed visits) for symptom management;" "Hospice Nurse to perform the following wound care to (unstageable wound of Rt (Right) Lateral Calf and Heel). Utilizing clean technique;" "Caregiver will provide wound care 4-5 times/week between nurse visits and PRN. Pt's son (name) manages wound care. Team to F/U (follow-up) with wound care orders/assessment." The hospital referral record fax dated 04/18/2022 documents: "Skin: gangrene of wound right foot;" "Pt (Patient) has 2 pressure ulcer(s) on the right leg;" "Pressure Ulcers on Legs: Pt has three ulcers; most severe is on right leg." The RN comprehensive assessment lacks documented evidence of the RN performing a wound assessment at the start of care. The RN comprehensive assessment lacks documentation of reflecting a complete and accurate picture of the patient's current integument/skin and wound status including the gangrene of wound on right foot. The subsequent RN/SN assessments and visits conducted on 4/23/2022, 4/29/2022, and 5/6/2022 failed to document an assessment for gangrene of wound on right foot. The Triage Call Coordination Note dated 5/9/2022 documents: "Assessment needed as to what are barriers to caregivers' involvement in performing wound care; Comments: Caregivers need instruction in how to perform wound care." The Triage Call Coordination Note dated 5/10/2022 documents: LPN SN "called to give report on wound:" "Assessment: Family was not present to instruct in wound dressing." The LPN (Licensed Practical Nurse)/SN Coordination Note dated 5/11/2022 documents: "Patient was seen on Monday 5/9/22 8:45PM-10:45PM;" "Rt heal (heel) and Rt 3, 4 and 5 toe(s) necrotic with pink wound surrounding eschar tissue. Areas are cleansed with wound wash Therahoney applied covered with 4x4 and pad and wrap with Kling gauze." The subsequent RN/SN visit and assessment notes dated 5/13/2022, 5/20/2022, 5/27/2022, 6/3/2022, 6/12/2022, and 6/22/2022 lack documented evidence of an assessment including the barriers to the caregiver in performing wound care and an assessment of the gangrene/necrotic toes of right foot. The 'Hospice IDG Comprehensive Assessment and Plan of Care Update Report(s)" dated 5/3/2022, 5/17/2022, 5/31/2022, 6/14/2022, and 6/28/2022 lacks documented evidence of the IDG updating the comprehensive assessment to include gangrene of wound on right foot. The RN Recert assessment and visit note dated 6/30/2022 documents: "Wound assessment done. Noted gangrene to bilateral lower extremities." The RN/SN assessment lacks documented evidence of a complete and accurate description including location of gangrene and the identified caregiver barriers to assist in developing the patient's individualized hospice plan of care. The 'Hospice IDG Comprehensive Assessment and Plan of Care Update Report(s)" dated 7/5/2022, months after the SOC dated 4/20/2022 , documents the IDG comprehensive assessment was updated to include the presence of gangrene: "gangrene to bilateral extremities." There is no documented evidence of the hospice ensuring that a comprehensive assessment of the patient's skin integrity/wound was conducted and updated to reflecting a complete and accurate picture of the patient's current integument/skin and wound status, and caregiver barriers in providing wound care. On 7/19/2022 at 12:30PM, the Director of Quality and the Clinical Director were interviewed and did not provide an explanation for the survey findings.

Based on clinical record review and staff interview conducted during the complaint investigation the hospice failed to ensure that the Interdisciplinary Group supervises patient care and develops plans of care based on comprehensive assessments for hospice patients. The Hospice failed to: Ensure all hospice care and services furnished to patients/families follow an individualized plan of care established by the hospice Interdisciplinary Group for 1 of 3 patients (refer to L-543) Ensure patients and primary care givers receive education and training in order to provide the care and services identified in the plan of care for 1 of 3 patients (refer to L-544) Ensure the hospice interdisciplinary group, in collaboration with the physician, review and revise individualized plans of care as changes occur, but no less frequently than every 15 days for 1 of 3 patients (refer to L-552) The cumulative effect of the systemic problems resulted in the hospice's failure to ensure that individualized plans of care are developed/reviewed and updated to meet the patient's wound care needs, failure to educate/train patient' family involved in wound care, and failure to address problems identified with patient's family when not following the plan of care.

Based on clinical record and interviews, the hospice failed to develop/revise and follow an individualized Plan of Care based on the patient's wound care needs, failed to ensure patient and/or patient's family/primary caregiver receive education and training in wound care, failed to ensure the family is following the Plan of Care and failed to ensure the Interdisciplinary Group (IDG) meetings address all wound care needs of the patient and including the family's concerns regarding the worsening of the wound. This was evident for one of three clinical records reviewed (Patient #1). Failure to develop/revise, coordinate and follow individualized Plans of Care to address all patient wound care needs has the potential to result in negative patient outcomes and harm. The findings are: 1. Patient #1 has a Start of Care date (SOC) of 04/20/2022 with diagnoses of "Cerebral Atherosclerosis, Peripheral Vascular Angioplasty Status, Pressure Ulcer of Other Site Unstageable, Pressure Ulcer of Right Heel Unstageable, Type 2 Diabetes Mellitus With Other Specified Complication and Chronic Kidney Disease, Stage 4 (Severe)" documented in the "Hospice Certification and Plan of Care" dated 04/20/2022 to 07/18/2022. Right Lower Extremity Wounds: The "Hospice Certification and Plan of Care" dated 04/20/2022 to 07/18/2022 documents: SN (Skilled Nurse) visit frequency, "2WK1 (two visits a week for one week), 1WK13 (one visit a week for 13 weeks), 4 PRN (four as needed visits) for symptom management;" "Hospice Nurse to perform the following wound care to (unstageable wound of Rt (Right) Lateral Calf and Heel). Utilizing clean technique. Cleanse with NS (Normal Saline) cover with bandage and change every day and PRN. Instruct caregiver in wound care. Caregiver will provide wound care 4-5 times/week between nurse visits and PRN. Pt's son (name) manages wound care. Team to F/U (follow-up) with wound care orders/assessment." The initial RN/SN Hospice Admission assessment dated 4/20/2022 lacks documented evidence of a wound assessment. The RN documents: "Pt has two unspecified wounds on her Rt lateral calf and Rt heel. Wound care had just been completed prior to visit so dressing could not be removed as HHA (non-hospice home health aide) was new and did not know location of wound supplies. She stated the Pt's (Patient's) son provided wound care early in the morning." The SN failed to perform a wound assessment in accordance with the plan of care. There is no documented evidence of the SN providing wound care education/training to the patient's son, who manages wound care and is involved in the plan of care. The Triage Call Coordination Note dated 5/9/2022 documents: "Initial call 2:14 PM" "Spoke with (name) (number) home care agency for 24 (hour) home health aide (non-hospice aide);" "Situation: wound is draining - wanted to know how we manage wound;" "Assessment needed as to what are barriers to caregivers involvement in performing wound care; Comments: Caregivers need instruction in how to perform wound care." The "Hospice - Team to AHS (After Hour Supervisor) Handoff Action Needed" Coordination Note dated 5/9/2022 documents: "Situation: Caregiver not performing wound care;" "Agency for 24 HR HHA - Reported that wound is draining and the caregivers are not dressing the wound;" "Please conduct a nurse visit to assess/dress wound and to re-educate family regarding wound care." The LPN (Licensed Practical Nurse)/SN Coordination Note dated 5/11/2022 documents: "Patient was seen on Monday 5/9/22 8:45PM-10:45PM;" "Wound to Rt lateral Ouer (outer) foot is cleanse with wound wash, pad dry, Therahoney gell (gel) is applied, dressing applied nonstick dressing 4x4 and pad and wrap with Kling gause (gauze). Rt heal (heel) and Rt 3, 4 and 5 toe(s) necrotic with pink wound surrounding eschar tissue. Areas are cleansed with wound wash Therahoney applied covered with 4x4 and pad and wrap with Kling gauze." The wound care orders for the right foot/heel does not include orders to apply Therahoney. There is no documented evidence of the LPN/SN providing wound care in accordance with the plan of care. The RN "Hospice - Weekday (Daytime) Triage Call Note" dated 5/10/2022 documents the LPN report to the RN: "SN Called to give report on wound;" "Patient with sacral, right lateral, heel with necrotic toes:" "Family was not present to instruct in wound dressing." The subsequent RN/SN Visit Note dated 5/13/2022 lacks documented evidence of the RN assessing and coordinating wound care for the patient's necrotic right toes. There is no documented evidence of the SN following-up with identifying PCG barriers to performing wound care and education/training with redemonstration with the patient's son/PCG. The SN visit notes dated 6/15/2022 lacks documented evidence of wound care and wound assessments of the right lower extremity wounds. The weekly SN Visit Notes dated 4/29/2022, 5/6/2022, 5/13/2022, 5/20/2022, 5/27/2022, 6/3/2022, 6/15/2022, 6/22/2022, 6/30/2022 lack documented evidence of the SN wound assessments including wound measurements of the right calf and heel. The SN/"RN Hospice Recert Assessment" Visit Note dated 6/22/2022, two months after the initial RN assessment, documents: " Intervention provided "instructed in performing wound care;" PCG (primary caregiver) and non-hospice aide were present. The SN note lacks documentation of re-demonstration, identifying barriers and the PCG's ability to providing wound care, as identified in the coordination note for the 5/9/2022 visit. The SN note lacks documentation of the relationship of PCG to the patient, including if the PCG present is the Patient's son who manages wound care. The "AHS (After Hour Supervisor) Triage Call Note" dated 6/25/2022 documents: "Patient's granddaughter "is requesting to have a visit from MD (Medical Doctor) or NP (Nurse Practitioner) to assess patient wound that she believes is infected and caller believes that RLE (right lower extremity) may possibly need to be amputated. Caller is requesting to discuss possibilities with the team and if team is unable to come up with a plan then caller would like patient to be assessed in a hospital." The "Nurse Practitioner(NP) Hospice Face to Face Encounter" Note dated 6/27/2022 documents: "B/L LE with necrosis and eschar, gangrene to right foot." The NP Late Entry Coordination Note dated 7/19/2022 for the visit on 6/27/2022 documents: "I spoke with (name) granddaughter;" "She had questions about options of care for the patient with regard to the right LE (lower extremity) gangrene;" "I explained that given no exudate, no odor or fever or other signs of infection, antibiotic would not be indicated at this time. Amputation/wound care and pain management were also discussed." There is no documented evidence of a discussion regarding the patient's son providing wound care. The "Hospice - WOCN (Wound Ostomy and Continence Nurse) Consult" Coordination Note dated 6/28/2022 documents: "Date of Consult 6-27-22;" "Received pictures of R (Right) Leg and R foot gangrene from (name) NP. No odor or exudate noted during the visit. Current Tx (Treatment) includes Xeroform. Recommendation for Palliation: DC(Discontinue) the Xeroform moist DSG (Dressing). Keep the sites clean and dry. Wound cleanser spray or ¼ strength Dakin's Solution to cleanse, PRN odor, paint necrotic tissue with Betadine, cover with ABD (abdominal) pads, gauze wrap BIW and PRN." The "Hospice Physician Order" dated 6/30/2022 documents the following changes to the wound care of the right lateral calf and heel: "Discontinue Xeroform. Hospice nurse to perform the following wound care to unstageable wounds of Rt lateral calf and heel. Utilizing clean technique - cleanse with wound cleanser spray or ¼ strength Darkin's (Dakin's)) Solution PRN odor, pain eschar with Betadine, cover with ABD (abdominal dressing) pad, apply gauze wrap twice a week and PRN. Instruct caregiver in wound care. Caregiver will provide wound (care) 2 times/week between nurse visit and PRN. Pt's son (name) manages wound care." The clinical record lacks documented evidence of wound care orders for the right lateral and heel prior to 6/27/2022 including Xeroform. The DME (Durable Medical Equipment) and Supplies records document the following delivery dates and wound care supplies: 4/26/2022 "Alginate Dressing," 4/30/2022 "Povidone (Betadine) Iodine Prep Solution," 5/8/2022 "Alginate Dressing; Sterile Petrolatum Impregnated Gauze Overwrap," 5/17/2022 "Sterile Petrolatum Impregnated Gauze Dressing," 5/28/2022 "Sterile Petrolatum Impregnated Gauze Dressing," and 6/23/2022 "Alginate Dressing; Sterile Petrolatum Impregnated Gauze Overwrap." The clinical record lacks documented evidence of how Betadine, Alginate Dressing, and Sterile Petrolatum Impregnated Gauze are used as part of the individualized plan of care for wound care. The clinical record lacks documented evidence of wound care orders including Alginate Dressing and Sterile Petrolatum Impregnated Gauze. The "Hospice Physician Order" dated 6/30/2022 documents wound care orders to paint with Betadine on the right calf and heel, two (2) months after Betadine was delivered to the patient's home (4/30/2022). On 07/20/2022 at 11:05 AM, the Clinical Director was interviewed and stated, the "Xeroform was delivered" as part of wound care supplies. She stated that Xeroform is the "Sterile Petrolatum Impregnated Gauze." The Clinical Director did not provide an explanation regarding the Plan of Care lacking documented evidence of including all wound care supplies delivered for use in the home. There is no documented evidence of the wound care being provided and coordinated to address the wound care needs in an individualized and comprehensive plan of care. The 'Hospice IDG Comprehensive Assessment and Plan of Care Update Report(s)" dated 5/17/2022, 5/31/2022, 6/14/2022, 6/28/2022, and 7/5/2022 lacks documented evidence of the Plan of Care being updated to address the patient's wound care needs of the necrotic right toes. The "Hospice Physician Order" dated 7/8/2022 documents: "Right toes: Hospice nurse to instruct caregiver to cleanse with wound cleanser, pat dry, pain (paint) with Betadine, ABD pad, wrap with conforming gauze and secure 3 x a week and PRN. Instruct caregiver in wound. Caregiver will provide wound care between nurse visits as needed." The "Hospice Physician Order" dated 7/8/2022 documents wound care orders for the right necrotic toes, two (2) months after the SN documented providing wound care to the toes on 5/9/2022. The SN wound care provided on 5/9/2022 did not include applying Betadine on the necrotic toes. Sacral Wound: The SN Visit Note dated 4/23/2022 documents wound assessment of Sacral Stage II Pressure Ulcer. The "Hospice Physician Order" dated 4/23/2022 documents: "Hospice nurse to perform wound care to sacrum, cleanse with wound cleanser or NS (Normal Saline), pad dry, apply Honey to wound, cover with Optifoam dressing 2 x weekly. In absence (absence) of VN (visiting nurse), PCG (primary caregiver) will perform wound care as neede(d)." The Hospice Physician Order dated 4/29/2022 document: "SN visits weekly and PRN" The weekly SN Visit Notes dated 5/20/2022, 5/27/2022, 6/3/2022, 6/15/2022 and 6/22/2022, lack documented evidence of the SN performing wound care and wound assessment of the sacrum wound. The SN notes document: "Wound assessed - No, caregiver completed wound care;" and "Wound care not provided caregiver completed care." The weekly SN visit notes dated 4/29/2022, 5/6/2022, 5/13/2022, and 6/30/2022 lack documented evidence of wound assessments including wound measurements of the sacral wound. The RN Hospice Recert Assessment/SN visit note dated 6/30/2022 documents: "Sacrum ulcer is covered with necrotic tissue. Sacral wound restaged to unstageable." The SN documents providing the same wound care as ordered on 4/23/2022. The SN visit note 6/30/2022 lacks documented evidence of the SN discussing current changes to the wound and current wound treatment. The "Hospice - Team to AHS Handoff Action Needed" Coordination Note dated 7/5/2022 documents: "Worsening sacral and heel wounds reported by COC (Coordinator of Care) require BIW (visit twice a week) and PRN wound care. Dressing soiled as per MLTC HHA (non-hospice aide) in the home;" "Call to son to request attention to wound;' "no answer from son." The SN Visit Note dated 7/5/2022 documents: "Sacrum is 8x12 shape like a butterfly with yellow harden tissue covering wound sites some odor. Area looks like it's breaking down. Area is cleanse with wound wash, pat dry, Medley Honey apply cover with bordered dressing." The SN Visit Note dated 7/8/2022 documents the following: "Unstageable pressure ulcer with small amount of serosanguinous to sacrum, moderate odor, picture taken and emailed it to (WOCN Name); ordered to continue to paint to paint necrotic tissue with Betadine and slough with Therahoney gel." The clinical record lacks documented evidence of the physician order for the change in wound care to the sacrum. The SN Visit Note dated 7/11/2022 documents: "Multiple necrotic wounds to bilateral, lower extremities, right toes and sacrum. Wound care performed to all sites;" "VN contacted patient's granddaughter (name) and informed her of increased nurse frequency for wound care and worsening sacral wound." The clinical record lacks documented evidence of consistency in wound care. The "Hospice IDG Comprehensive Assessment and Plan of Care Update Reported" for IDG Meeting dated 7/5/2022 documents: "Evidence of decline per SW observation and/or caregiver report: Pt's wounds are worse and there is concern about who is caring for the wounds." The "Hospice IDG Comprehensive Assessment and Plan of Care Update Reported" for IDG meetings dated 5/17/2022, 5/31/022, 6/14/2022, and 6/28/2022 lack documented evidence of the IDG addressing the problem that was initially identified on 5/9/2022. The IDG failed to address concerns about the primary caregiver/patient's son not performing wound care, the need to assess for barriers to caregiver involvement in performing wound care, and the need for re-education/training in wound care. The MSW Coordinator Note dated 7/6/2022 documents: SW (Social Worker) called granddaughter - "asked her about the wound care and what Pt's son is doing in terms of wound care as well as giving her meds as home attendant can't do it;" "SW asked if we could meet there on SW's next visit, and she agreed to meet there next Tuesday afternoon to discuss Pt's Care." The clinical record lacks documented evidence of the PCG receiving instructions/training, including re-demonstration, regarding changes in wound care orders dated 06/30/2022 and 7/8/2022. There is no documented evidence of coordination with PCG on wound care being provided as written in the plan of care. The clinical record lacks documented evidence of coordination of care as evidence by wound care supplies being delivered and not included in the Plan of Care for wounds, wound care being provided without updating the Plan of Care, lack of coordination with the PCG regarding following the Plan of Care, and IDG not updating the Plan of Care to address all wounds in a timely manner. The "Hospice- AHS (After Hour Supervisor) Triage Call Note" dated 07/11/2022 documents: "Time of initial call 8:24P;" Spoke with granddaughter; "Comments: Patient's wound is infected and has maggots coming from small toe. Daughter (Granddaughter) called 911 and 911 arrived while on the phone with this nurse." The "Hospice - ED (Emergency Department) Intervention/Follow-up" Coordination Note dated 07/12/2022 documents: "Date of Emergency room visit? 7/11/22; What is the reason for the ED visit? Maggots in wound; What is the clinical outcome of the visit? Patient currently still in the ER but will be admitted this morning for gangrene." On 7/19/2022 at 2:20 PM, the patient's son was interviewed and stated the hospice "did not teach me" how to perform the wound care; "I did not like how they bandage the wound on the right leg;" "every time the nurse bandaged the feet it would get worse;" "I would unbandage it and have it open to air so the wound can dry out." On 7/20/2022 at 1:15PM, the patient's granddaughter was interviewed and stated that patient has had gangrene of the right foot including the toes since last year. The granddaughter stated that on 7/11/2022, the non-hospice aide "called her crying and said she smell something coming from the right foot, the aide cut the bandage and saw maggots coming out;" the granddaughter stated she "instructed the aide to call 911." The granddaughter said the patient had surgery including right leg amputation above the knee. On 7/20/2022 at 4:10PM, the Clinical Director and the RN COC were interviewed. The RN COC stated that she conducted SN visits on 6/30/2022, 7/8/2022 and 7/11/2022. The RN COC stated "no, I did not" provide wound care instructions/training to the primary caregiver (patient's son) when wound care changes were made 6/30/2022 and 7/8/2022. The RN COC stated, "I was told by the WOCN" about the new wound care to sacral on 7/8/2022;" " I forgot to put in the new order."

Based on clinical record reviews and interviews, the hospice failed to ensure that the patients and/or patient's family/ receive wound care education and training identified in the Plan of Care (POC). This was evident in one (1) of three (3) clinical records reviewed of patients with wounds (Patient #1). Failure to ensure that each patient or the primary care giver(s) receive wound care education and training, identified in the Plan of Care, has the potential to result in negative patient outcome and harm. The findings are: 1. Patient #1 has a Start of Care date (SOC) of 04/20/2022 with diagnoses of "Cerebral Atherosclerosis, Peripheral Vascular Angioplasty Status, Pressure Ulcer of Other Site Unstageable, Pressure Ulcer of Right Heel Unstageable, Type 2 Diabetes Mellitus With Other Specified Complication and Chronic Kidney Disease, Stage 4 (Severe)" documented in the "Hospice Certification and Plan of Care" dated 04/20/2022 to 07/18/2022. The Hospice Plan of Care and physician orders document the patient's family involvement in wound care. The "Hospice Certification and Plan of Care" dated 4/20/2022 to 7/18/2022 documents: SN (Skilled Nurse) Visit frequency, "2WK1 (two visits a week for one week), 1WK13 (one visit a week for 13 weeks), 4 PRN (four as need visits) for symptom management;" "Hospice Nurse to perform the following wound care to (unstageable wound of Rt (Right) Lateral Calf and Heel). Utilizing clean technique. Cleanse with NS (Normal Saline) cover with bandage and change every day and PRN. Instruct caregiver in wound care. Caregiver to provide wound care 4-5 times week between visits and PRN. Pt's son (name) manages wound care. Team to F/U (follow-up) with wound care orders/assessment." The "Hospice Physician Order" dated 4/23/2022 documents: "Hospice nurse to perform wound care to sacrum, cleanse with wound cleanser or NS (Normal Saline), pad dry, apply Honey to wound, cover with Optifoam dressing 2 x weekly. In absence (absence) of VN (visiting nurse), PCG (primary caregiver) will perform wound care as neede(d)." The "Hospice Physician Order" dated 6/30/2022 documents the following changes to the wound care of the right lateral calf and heel: "Discontinue Xeroform. Hospice nurse to perform the following wound care to unstageable wounds of Rt lateral calf and heel. Utilizing clean technique - cleanse with wound cleanser spray or ¼ strength Darkin's (Dakin's)) Solution PRN odor, pain eschar with Betadine, cover with ABD (abdominal dressing) pad, apply gauze wrap twice a week and PRN. Instruction caregiver in wound care. Caregiver will provide wound 2 times/week between nurse visit and PRN. Pt's son (name) manages wound care." The "Hospice Physician Order" dated 7/8/2022 documents: "Left distal lower leg: Hospice nurse to instruct caregiver to cleanse with wound cleanser, pat dry, pain (paint) with Betadine, ABD pad, wrap with conforming gauze and secure 3 x a week and PRN. Instruct caregiver in wound. Caregiver will provide wound care between nurse visits as needed; Right toes: Hospice nurse to instruct caregiver to cleanse with wound cleanser, pat dry, pain (paint) with Betadine, ABD pad, wrap with conforming gauze and secure 3 x a week and PRN. Instruct caregiver in wound. Caregiver will provide wound care between nurse visits as needed." The Triage Call Coordination Note dated 5/9/2022 documents: "Initial call 2:14PM" "Spoke with (name) (number) home care agency for 24 (hour) home health aide (non-hospice aide);" "Situation: wound is draining - wanted to know how we manage wound;" "Assessment needed as to what are barriers to caregivers' involvement in performing wound care; Comments: Caregivers need instruction in how to perform wound care." The Coordination Notes - Hospice Team to AHS Handoff Action Needed dated 5/9/2022 documents: "Please conduct a nurse visit to assess/dress wound and to re-educate family regarding wound care." The Coordination Noted dated 5/11/2022 documents: SN PRN visit, "Pt is seen on Monday 5/9/22 8:45PM-10:45PM." The Triage Call Coordination Note dated 5/10/2022 documents: LPN SN "called to give report on wound:" "Assessment: Family was not present to instruct in wound dressing." The Coordination Note dated 7/5/2022 documents: "worsening sacral and heel wounds reported by COC (Coordinator of Care) require BIW (two visits a week) and PRN (as needed) wound care. Dressing soiled as per MLTC HHA in the home." The MSW Coordinator Note dated 7/6/2022 documents: SW called granddaughter - "asked her about the wound care and what Pt's son is doing in terms of wound care;" "SW asked if we could meet there on SW's next visit, and she agreed to meet there next Tuesday afternoon to discuss Pt's Care." The "Hospice IDG Comprehensive Assessment and Plan of Care Update Reported" for IDG Meeting date 7/5/2022 documents: "Evidence of decline per SW observation and/or caregiver report: Pt's wounds are worse and there is concern about who is caring for the wounds." The SN visit notes dated 4/29/2022, 5/27/2022, 6/3/2022, 6/7/2022, 6/30/2022, 7/8/2022 and 7/11/2022 document intervention provided : "instructed in performing wound care" the SN narrative note documents the non-hospice aide being present during the visits. There is no documented evidence of the education and training being provided to the patient's family (patient's son) regarding how to perform wound care as directed on the Plan of C are. The SN/"RN Hospice Recert Assessment" Visit Note dated 6/22/2022, two months after the initial RN assessment, documents: intervention provided "instructed in performing wound care;" PCG (primary caregiver) and non-hospice aide were present. The SN note lacks documented evidence of re-demonstration, identifying barriers and the PCG's ability to providing wound care, as identified in the coordination note dated 5/9/2022 visit. The SN note lacks documented evidence of the relationship of PCG to the patient, and if the PCG who is present, is the Patient's son, who manages the wound care. There is no documented evidence of redemonstration and documentation of the PCG ability to provide wound care, and the PCG receiving instruction regarding changes in wound care orders on 06/30/2022 and 7/8/2022. The clinical record lacks documented evidence of the SN providing education and training, including redemonstration on how to perform wound care during SN visits conducted from 4/20/2022 to 7/11/2022 as directed in the Plan of Care. On 7/19/2022 at 2:20 PM, the patient's son was interviewed and stated the hospice "did not teach me" how to perform the wound care;" "I did not like how they bandage the wound on the right leg;" "every time the nurse bandaged the feet it would get worse;" "I would unbandage it and have it open to air so the wound can dry out;" The Hospice failed to ensure that the patient's family/patient's son, received education and training, with re-demonstration, regarding wound care and that he understands the responsibility for wound care and services as identified in the plan of care. On 7/20/2022 at 11:05AM, the Clinical Director, and the RN who conducted the initial assessment were interviewed, and the RN stated "the (non-hospice) aide told me the patient's son did the wound care;" she stated she "did not have a conversation with the son" about wound care. On 7/20/2022 at 4:10PM, the Clinical Director and the RN COC were interviewed. The RN COC stated that she conducted SN visits on 6/30/2022, 7/8/2022 and 7/11/2022. The COC stated "no, I did not" provide wound care instructions to the primary caregiver (patient's son) on changes wound care orders dated 6/30/2022 and 7/8/2022.

Based on clinical record review, hospice policy and procedure review, and staff interviews, the hospice failed to ensure the Interdisciplinary Group (IDG) reviewed and revised the individualized Plan of Care (POC) as the patient's care needs change, but no less frequently than every fifteen (15) days. This was evident for one (1) of three (3) patients with wounds (Patient #1). Failure of the IDG to develop, review, and revise the POC has the potential for unmet patient needs and inadequate care. The findings are: The Hospice "Initial and Comprehensive Assessment" Policy documents: "The POC (Plan of Care) is updated as frequently as the condition of the patient requires but no less frequently than every 15 days." 1. Patient #1 has a Start of Care date (SOC) of 04/20/2022 with diagnoses of "Cerebral Atherosclerosis, Peripheral Vascular Angioplasty Status, Pressure Ulcer of Other Site Unstageable, Pressure Ulcer of Right Heel Unstageable, Type 2 Diabetes Mellitus With Other Specified Complication and Chronic Kidney Disease, Stage 4 (Severe)" documented in the "Hospice Certification and Plan of Care" dated 04/20/2022 to 07/18/2022. The Triage Call Coordination Note dated 5/9/2022 documents: "Assessment needed as to what are barriers to caregivers' involvement in performing wound care; Comments: Caregivers need instruction in how to perform wound care." The clinical record lacks documented evidence of an assessment including the barriers to the caregiver (patient's son) performing wound care. The LPN (Licensed Practical Nurse)/SN Coordination Note dated 5/11/2022 documents: "Patient was seen on Monday 5/9/22 8:45PM-10:45PM;" "Rt heal (heel) and Rt 3, 4 and 5 toe(s) necrotic with pink wound surrounding eschar tissue. Areas are cleansed with wound wash Therahoney applied covered with 4x4 and pad and wrap with Kling gauze." There is no documented evidence the IDG Plan of Care being reviewed and revised to address wound care barriers and wound care order for the right necrotic toes. The "Hospice - WOCN (Wound Ostomy and Continence Nurse) Consult" Coordination Note dated 6/28/2022 documents: "Date of Consult 6-27-22;" "Received pictures of R (Right) Leg and R foot gangrene from (name) NP. No odor or exudate noted during the visit. Current Tx (Treatment) includes Xeroform. Recommendation for Palliation: DC(Discontinue) the Xeroform moist DSG (Dressing)." The "Hospice Physician Order" dated 6/30/2022 documents the following changes to the wound care of the right lateral calf and heel: "Discontinue Xeroform." The clinical record lacks documented evidence of wound care orders for the use of Xeroforrm as part of patient's individualized Plan of Care. There is no documented evidence of the POC being revised to include Xeroform. The DME (Durable Medical Equipment) and Supplies records document the following wound care delivery dates and supplies: "4/26/2022 "Alginate Dressing," 4/30/2022 "Povidone (Betadine) Iodine Prep Solution," 5/8/2022 "Alginate Dressing; Sterile Petrolatum Impregnated Gauze Overwrap," 5/17/2022 "Sterile Petrolatum Impregnated Gauze Dressing," 5/28/2022 "Sterile Petrolatum Impregnated Gauze Dressing," and 6/23/2022 "Alginate Dressing; Sterile Petrolatum Impregnated Gauze Overwrap." The clinical record lacks documented evidence of wound care orders to use Betadine, Alginate Dressing, and Sterile Petrolatum Impregnated Gauze as part the individualized the Plan of Care. The "Hospice Physician Order" dated 6/30/2022 documents wound care orders to paint with Betadine on the right calf and heel, two months after Betadine was delivered to the patient's home. The "Hospice IDG Comprehensive Assessment and Plan of Care Update Reported" for IDG Meeting dated 7/5/2022 documents: "Evidence of decline per SW observation and/or caregiver report: Pt's wounds are worse and there is concern about who is caring for the wounds." The "Hospice IDG Comprehensive Assessment and Plan of Care Update Reported" for IDG meetings dated 5/17/2022, 5/31/022, 6/14/2022, and 6/28/2022 lack documented evidence of the IDG addressing the problem that was initially identified on 5/9/2022. The 'Hospice IDG Comprehensive Assessment and Plan of Care Update Report(s)" dated 4/26/2022, 5/3/2022, 5/17/2022, 5/31/2022, 6/14/2022, and 6/28/2022 lack documented evidence that the IDG Plan of Care was reviewed and updated to address changes in the patient's wound care needs and reflect current wound treatment. The "Hospice Physician Order" dated 7/8/2022 documents a wound care order for the right toes. The subsequent "Hospice IDG Comprehensive Assessment and Plan of Care Update Report(s)" dated 7/11/2022 documents the 7/8/2022 order for the right toes, two months after the SN performed the initial wound care on the toes (5/9/2022). The clinical record lacks documented evidence of the IDG Plan of Care being updated as frequently as the condition of the patient requires but no less frequently than every 15 days. On 7/19/2022 at 12:30PM, the Director of Quality and the Clinical Director were interviewed and did not provide an explanation for the survey findings. On 07/20/2022 at 11:05 AM, Clinical Director was interviewed and stated, the "Xeroform was delivered" as part of wound care supplies. She stated that Xeroform is the "Sterile Petrolatum Impregnated Gauze." The Clinical Director did not provide an explanation regarding the plan of care lacking documented evidence of including all wound care supplies delivered for use in the home.

Based on clinical record review and interview, the hospice failed to ensure adequate supervision of the nursing services and care to ensure the wound care needs of the patient are met. Specifically, the hospice failed to: Ensure the Registered Nurses comprehensive assessments were of sufficient scope to identify all the patient's wound care needs in order to promote the patient's well-being and comfort throughout the patient's dying process for one (1) of three (3) patients with wounds (refer to L591). Ensure the Registered Nurses update the comprehensive assessments or communicate changes in the patient wound care needs and changes in change in wound care orders for one (1) of three (3) patients with wounds (refer to L591). Ensure Skilled Nurses perform wound care in accordance with the Plan of Care and report any inconsistency with wound care orders (refer to L591). The cumulative effect of the systemic issues identified in the agency's failure to ensure supervision of nursing care and services has the potential for negative patient outcomes, and resulted in the likelihood of patient harm for Patient #1.

Based on clinical record review and staff interview, the hospice failed to ensure adequate supervision of the nursing services and care to ensure wound care needs of the patient are met. This was evident for one (1) of three (3) clinical records reviewed of patients with wounds (Patients #1). Failure to adequately supervise nursing staff has the potential to result in the provision of inappropriate and/or incorrect care and negative patient outcomes. The findings are: 1. Patient #1 has a Start of Care date (SOC) of 04/20/2022, discharge date of 07/11/2022, with the following diagnoses: "Cerebral Atherosclerosis," "Peripheral Vascular Angioplasty Status," "Pressure Ulcer of Other Site Unstageable," "Pressure Ulcer of Right Heel Unstageable," "Type 2 Diabetes Mellitus With Other Specified Complication and Chronic Kidney Disease, Stage 4 (Severe)" documented in the "Hospice Certification and Plan of Care" dated 04/20/2022 to 07/18/2022. The referral hospital record fax dated 04/18/2022 documents: "Skin: gangrene of wound on right foot;" "Pt has 2 pressure ulcer(s) on the right leg;" "Pressure Ulcers on Legs: Pt has three ulcers; most severe is on right leg." The "Hospice Certification and Plan of Care" dated 04/20/2022 to 07/18/2022 documents: "SN Visit frequency, "2WK1 (two visits a week for one week), 1WK13 (one visit a week for 13 weeks), 4 PRN (four as need visits) for symptom management;" "Hospice Nurse to perform the following wound care to (unstageable wound of Rt (Right) Lateral Calf and Heel). Utilizing clean technique. Cleanse with NS (Normal Saline) cover with bandage and change every day and PRN. Instruct caregiver in wound care. Caregiver to provide wound care 4-5 times week between visits and PRN. Pt's son (name) manages wound care. Team to F/U (follow-up) with wound care orders/assessment." The "RN (Registered Nurse) Hospice Admission" comprehensive assessment dated 04/20/2022 documents of the RN/SN performing wound assessment and wound care. During the initial comprehensive assessment to determine the wound care needs of the patient, the RN documents: "Wound assessment: Rt Dist Calf, Rt, Unstage: Wound assessed- NO. Caregiver completed care; Rt Heel, Rt Unstage - Wound assessed- NO. Caregiver completed care;" "Narrative: The non-hospice aide, "stated that pt's son provided wound care early in the morning." There is no documented evidence of the RN instructing the patient's son on performing wound care. The initial RN comprehensive assessment lacks documented evidence of a complete and accurate picture of the patient's current integument/skin and wound status, including gangrene of the right foot, to assist in developing the patient's individualized hospice Plan of Care. On 07/20/2022 at 11:05 AM, the SOC RN and the Clinical Director were interviewed, and the RN stated that she did not assess or perform wound care on 4/20/2022. The subsequent RN/SN Visit note dated 4/23/2022 documents a wound assessment of sacral and right lateral calf and heel wounds. The RN's wound assessment lacks documented evidence to the presence and location of the gangrene wound. The SNs do not consistently document wound measurements as part of their wound assessments. The SNs Visit Notes dated 4/23/2022 documents an initial sacral wound measurement and the next documented measurement was on 6/12/2022, almost two months later. The SNs documented right lateral calf and heel wound measurements on 4/23/2022, 6/30/2022 (two months later) and 7/8/2022. The SN documented three wound measurements from Start of Care date (4/20/2022) to Discharge Date (7/11/2022) for the right lateral calf and heel wounds. The weekly SNs Visit Notes lack documented evidence the SNs conducting wound assessments and wound care. The clinical record lacks documented evidence of sacral wound assessment and wound care on 5/20/2022, 5/27/2022, 6/15/2022 and 6/22/2022. The clinical record lacks documented evidence of right lateral calf and heel wound assessments and wound care on 4/29/2022, 5/6/2022, 5/13/2022, 5/20/2022, and 6/22/2022. The clinical record lacks documented evidence of SNs consistently assessing the wounds in order to track wound status and to timely address wound care needs. The Triage Call Coordination Note dated 5/9/2022 documents: "Initial call 2:14PM" "Spoke with (name) (number) home care agency for 24 (hour) home health aide (non-hospice aide);" "Situation: wound is draining - wanted to know how we manage wound;" "Assessment needed as to what are barriers to caregivers' involvement in performing wound care; Comments: Caregivers need instruction in how to perform wound care." The RN Coordination Note "Hospice - Team to AHS Handoff Action Need" dated 5/9/2022 documents: "Follow-up comment entered by (name) RN on 05/09/2022 assigned to SN (LPN's name);" "Please conduct a nurse visit to assess/dress wound and to re-educate family regarding wound care;" "Assessment: caregiver education needed - assessment may be needed to identify barriers to caregiver engagement with wound care." The LPN/SN Coordination Note dated 5/11/2022 documents: "Patient was seen on Monday 5/9/22 8:45PM-10:45PM;" "Wound to Rt lateral Ouer (outer) foot is cleanse with wound wash, pad dry, Therahoney gell (gel) is applied, dressing applied nonstick dressing 4x4 and pad and wrap with Kling gause (gauze). Rt heal (heel) and Rt 3, 4 and 5 toe(s) necrotic with pink wound surrounding eschar tissue. Areas are cleansed with wound wash Therahoney applied covered with 4x4 and pad and wrap with Kling gause." The wound care orders for the right foot/heel do not include orders to apply Therahoney. The LPN/SN did not provide wound care in accordance to wound care orders in the Plan of Care. The LPN/SN performed wound care to right toes without a physician's order. The RN "Hospice - Weekday (Daytime) Triage Call Note" dated 5/10/2022 documents the LPN's report to the RN/ SN "Called to give report on wound;" "Patient with sacral right lateral, heel with necrotic toes:" "Family was not present to instruct in wound dressing." The subsequent RN/SN visit note dated 5/13/2022 lacks documented evidence of the RN assessing and collaborating with a supervisor or physician to obtain wound care orders for the necrotic right toes. The RN Visit Note lacks documented evidence of the RN addressing barriers to caregiver/patient's son in performing wound care, including education and training with re-demonstration. The "Hospice Physician Order" dated 7/8/2022 documents wound care order for the right toes, two months after the 5/9/2022 SN visit noting the necrotic right toes. The DME (Durable Medical Equipment) and Supplies records document the following delivery dates and wound care supplies: 4/26/2022 "Alginate Dressing," 4/30/2022 "Povidone (Betadine) Iodine Prep Solution," 5/8/2022 "Alginate Dressing; Sterile Petrolatum Impregnated Gauze Overwrap," 5/17/2022 "Sterile Petrolatum Impregnated Gauze Dressing," 5/28/2022 "Sterile Petrolatum Impregnated Gauze Dressing," and 6/23/2022 "Alginate Dressing; Sterile Petrolatum Impregnated Gauze Overwrap." The clinical record lacks documented evidence of wound care orders that include Betadine, Alginate and Sterile Petrolatum Impregnated Gauze Dressing. The SN visit notes lacks documenting evidence of the SN performing wound care using these wound care supplies. The clinical record lacks documented evidence of the Registered Nurse/SN reporting inconsistencies with wound care orders and wound care supplies in the home. The Coordination Note "Hospice - WOCN (Wound Ostomy and Continence Nurse) Consult" dated 6/28/2022 documents: "Date of Consult 6-27-22;" "Received pictures of R (Right) Leg and R foot gangrene from (name) NP. No odor or exudate noted during the visit. Current Tx (Treatment) includes Xeroform. Recommendation for Palliation: DC(Discontinue) the Xeroform moist DSG (Dressing). Keep the sites clean and dry." The "Hospice Physician Order" dated 6/30/2022 documents the following changes to the wound care of the right lateral calf and heel: "Discontinue Xeroform." The clinical record lacks documented evidence of the SNs performing wound care using Xeroform, prior to the discontinue order, as part of the current wound treatment. On 07/20/2022 at 11:05 AM, Clinical Director was interviewed and stated, the "Xeroform was delivered" as part of wound care supplies. She stated that Xeroform is the "Sterile Petrolatum Impregnated Gauze." The Clinical Director did not provide an explanation for the Plan of Care lacking documented evidence of wound care orders that include wound care supplies delivered to the patient's home. The "Nurse Practitioner (NP) Hospice Face to Face Encounter" Visit Note Report dated 06/27/2022 documents: "Multiple wounds to B/L(bilateral) LE (lower extremities) with necrosis and eschar, gangrene to right foot, open wound to posterior LE." The RN Hospice Recert Assessment Visit Note Report dated 06/30/2022 documents: "Noted with multiple wounds to bilateral lower extremities;" "Noted with gangrene to bilateral lower extremities." The "Hospice - WOCN (Wound Ostomy and Continence Nurse) Consult" Coordination Note dated 6/28/2022 documents: "Date of Consult 6-27-22;" "Received pictures of R (Right) Leg and R foot gangrene from (name) NP:" "Recommendation for Palliation: DC(Discontinue) the Xeroform moist DSG (Dressing). Keep the sites clean and dry; Wound cleanser spray or 1/4 strength Dakin's Solution to cleanse, PRN (for) odor, paint necrotic tissue with Betadine, cover with ABD pads, gauze wrap BIW and PRN." The subsequent RN Hospice Recert Assessment visit note dated 6/30/2022 documents: "Gangrene to all right toes, unstageable pressure ulcer to bilateral distal leg." The "Hospice Physician Order" dated 6/30/2022 documents the changes to the wound care of the right lateral calf and heel as per WOCN recommendation. The Physician Order did not include wound care order for the right toes. The LPN/SN Visit Note dated 7/5/2022 documents the LPN/SN performing wound care to the right toes including painting toes with Betadine Solution. The Hospice Physician Order dated 7/8/2022 documents: "verbal" wound care order for the right toes was obtained on 7/8/2022, a week after the WOCN's recommendation for wound care. The LPN/SN performed wound care of the right toes without a physician's order. The clinical record lacks documented evidence of the RN addressing or collaborating with the physician on need for wound care order for the right toes during the Recertification Visit on 6/30/2022, prior to the LPN/SN visit. The RN Hospice Recert Assessment/SN visit note dated 6/30/2022 documents: "Sacrum ulcer is covered with necrotic tissue. Sacral wound restaged to unstageable." The SN documents providing the same wound care as ordered on 4/23/2022. The SN Visit Note dated 7/8/2022 documents the following: "Unstageable pressure ulcer with small amount of serosanguinous to sacrum, moderate odor, picture taken and emailed it to (WOCN Name); ordered to continue to paint necrotic tissue with Betadine and slough with Therahoney gel." The "Hospice-WOCN Consult" Coordination Note dated 7/8/2022 documents: "Received picture of sacral unstageable" pressure ulcer; "current Tx (treatment) includes Honey wound gel: Recommendation for Palliation: Wound cleanser spray or ¼ strength Dakin's Solution to cleanse, PRN (for) odor; DC (discontinue) the Honey wound gel and paint the necrotic tissue with Betadine skin prep periwd, pad with gauze, secure with Optifoam gentle or Stratasorb 2-3 x week and PRN if soiled." The clinical record lacks documented evidence of the RN/SN obtaining a written physician's order for the changes in wound as per the WOCN's recommendation for wound care for the sacral unstageable pressure ulcer. The RN performed wound care without a physician's order. There is no documented evidence of the hospice supervising and providing nursing care and services to ensure wound care needs are met, failed to ensure the RN identifies and address all wound care needs in the comprehensive assessment and updates assessments, and failed to ensure wound care is coordinated and provided in accordance with the plan of care. On 7/20/2022 at 4:10PM, the Clinical Director and the RN COC were interviewed. The RN COC stated that she conducted SN visits on 6/30/2022, 7/8/2022 and 7/11/2022. The RN COC stated confirmed the present of gangrene of right toes during the visit on 6/30/2021. " The RN COC stated, "I was told by the WOCN" about the new wound care to sacral on 7/8/2022;" "I forgot to put in the new order." There was no additional explanation provided for the survey findings.

Based on Clinical record review and staff interview the agency failed to ensure that any new change/ modification in the medications ordered by a physician includes a discontinuation order of the previously ordered medication. This was evident for one of three clinical records reviewed (Patient # 1). Failure to ensure that any new change/ modification in the medications ordered by a physician includes a discontinuation order of the previously ordered medication, has the potential for negative patient outcomes. The Findings are: Patient #1 has a Start of Care date of 12/16/21 with the following diagnoses: " Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung: Chronic Obstructive Pulmonary Disease, Unspecified: Essential (Primary) Hypertension: Hyperlipidemia, Unspecified: Type 2 Diabetes Mellitus without Complications: Age-Related Osteoporosis W/O Current Pathological Fracture: Acute Angle -Closure Glaucoma, Unspecified Eye" documented on the Hospice Certification and Plan of Care for Certification Period 12/16/2021 to 3/15/2022. Date of Death: 01/31/2022. The VNSNY Hospice and Palliative Care Order documents: "Order Date: 1/25/2022 11:2PM - Order Description: Medication: Current Ordered Medications: Type: Start Date: 1/25/2022: Add: Medication -Morphine ER 30 mg tablet, Extended Release -Dose: 1 tablet - Frequency: Every 12 hours- Route: Oral-" The Client Medication Report documents: "Client: Patient#1: Patient Medications: Start Date: 1/25/2022: Morphine ER 30 mg tablet, Extended Release -Dose: 1 tablet - Frequency: Every 12 hours- Route: Oral- Discontinued By : Employee #4 - 01/31/2022." The Client Medication Report documents: "Start Date: 1/29/2022 Morphine Concentrate 100mg/5ml (20mg/ml) Oral Solution hourly Oral PRN." The VNSNY Hospice and Palliative Care Order documents: "Order Date: 1/28/2022 2:01 PM - Order Description: Late entry per note dated 01/28/2022 : Medication: Current Ordered Medications: Type: DC - Discontinue : Medication -Morphine ER 30 mg tablet, Extended Release -Dose: : Start Date: 1/25/2022 - Dose: 1 tablet - Frequency: Every 12 hours- Route: Oral- DC Date 1/28/2022. Approved/ Processed By- RN- Date: 04/15/2022 : Licensed Practitioner Signature - MD- Date: 04/15/2022." The clinical record lacks documented evidence of a physician order to discontinue Morphine ER 30mg tablet, Extended Release, 1 tablet Every 12 hours- Route: Oral prior to 4/15/2022. On 4/15/2022 at 2:30PM the Director of Clinical Services and the Hospice Medical Doctor was interviewed and stated," the verbal order to discontinue the Morphine ER was received on 1/28/2022 , the order was not signed by the Physician."

Based on record review and interview, the hospice failed to protect and promote the rights of all patients. The Hospice failed to: Ensure a timely response to all patient and family calls for assistance. Failure to respond timely to calls for assistance has the potential for negative patient outcomes. (L 512) The hospice's failure to ensure all patients' rights are respected presents the likelihood for serious injury, serious harm, serious imparement or premature death to the patients under the hospice's care.

Based on records reviews and staff interviews, the Hospice failed to ensure the protection of rights of all patients that requires timely response to calls identifying patient distress. This was evident in four (4) of twenty-three (23) clinical records reviewed. (Patient #1, #2, #11, and #16). Failure to ensure that all patients receive timely response to evaluate and manage pain and symptoms, including receiving ordered medications, has the potential and likelihood for negative patient outcomes. The Finding Are: On 02/16/2022, at 03:00 PM, surveyor requested policy and procedure addressing timeframe for response to patient and family calls. On 02/16/2022, at 04:00 PM, the Director of Quality Hospice and Supervisor Quality Provider Services were interviewed and stated: "Response time depends on multiple factors. Each patient's situation is unique. We do not have policy with time frame for response." 1. Patient #11 has Start of Care date of 10/02/2021 with diagnosis "Chronic Systolic (Congestive) Heart Failure" as documented on the Hospice Certification and Plan of Care (POC), dated 10/06/2021 to 01/03/2022. The Client Episode Coordination Notes Report dated 11/22/2021 documents: "Hospice - Incoming Call (CSR - Customer Service Representative) Message Left; Note: Message Left For: Queens West Team Topic: RN visit Time Call 12:41PM. Call Note: Niece(name) is requesting a nurse visit for today. She stated that HHA (Home Health Aide) Called her and told her that the PT (patient) is complaining about chest pain and her heart hurts. Niece (name) would like a nurse to check and evaluate the patient. Please follow up at (niece phone number) to confirm that a nurse will visit." The Client Episode Coordination Notes Report dated 11/23/2021 documents: "Hospice - Incoming Call (CSR) Connected. Time of Call 2:24 PM. Call note: Niece (name) calling to inform that patient has passed away today at 11/23 at The Mount Sinai Hospital. Caller stated she had call yesterday 11/22 regarding urgent patient matter about patient not doing well with request to have clinical visit. 911 was contacted patient was brought to hospital. Caller not sure if hospice was informed of patient passing. Family is in the process of funeral arrangements. Call connected to (R. name of the hospice team member)." The Client Episode Coordination Notes Report dated 11/23/2021 2:26 PM documents: "Hospice - Death Notification Death reported to VNSNY by: Niece DOD (day of death) 11/23/21; TOD (time of death) 10:30 AM not sure if that was exact time; Location: GIP Mount Sinai Hospital." The clinical record has no documented evidence of the patient's niece being contacted or visit being scheduled. On 02/16/2022, at 02:00 PM, the Clinical Supervisor was interviewed and stated: "The proper escalation process wasn't handled, and Customer Service Representative did not notify clinical supervisor about this call." 2. Patient #1 has a hospice admission date of 1/14/2022, discharge date of 1/21/2022, and a re-admission date of 1/30/2022, with a terminal diagnosis of Malignant Neoplasm of Endometrium, and comorbid related diagnoses Emphysema Unspecified and Unspecified Asthma Uncomplicated documented on the Hospice Plan of Care (POC) dated 1/14/2022 to 4/13/2022. The Hospice Plan of Care dated 1/14/2022 to 4/13/2022 documents: Medications - "Acetaminophen 300mg-Codeine 30 mg tablet every 6 hours/PRN (as needed). reason: pain; Methadone 5mg (milligram)/5ml (milliliter) Oral Solution 5mg every 4 hours (start 02/14/2022), reason: pain;" "Ipratropium-Albuterol 3mg (2.5 based)/ 3ml Nebulization Soln (Solution) (Start 01/14/2022), reason: SOB (shortness of breath) & wheezing);" "Hospice Nurse to instruct in performing inhalation therapy and care for equipment." There is no documented evidence that the Hospice nurse determined that the patient had the necessary instruction for performing inhalation therapy at the start of care. The Hospice Coordination Notes - Urgent Call connected Note dated 1/17/2022 2:16 PM (time of call) document: "Caregiver (a non-hospice aide) (for) patient (name) called about nebulizer not received only the medication received." The Hospice Coordination Notes - Hospice After Hours Supervisor (AHS) Inbound Triage Call Note dated 1/17/2022 2:16 PM (time of call) document: "Situation: Has not received nebulizer machine; background: received Duo Neb vials (nebulizer medication) from pharmacy last night; Assessment: Order placed via (vendor name) for stat urgent delivery for today." The Hospice RN Visit Note dated 1/19/2022 4:06 PM documents: "Duo Neb regimen via nebulized (nebulizer) instructed to caregiver. Pt requires Methadone prefilled to be administered by caregiver: VN (visiting nurse) collaborated with Dr. (name) to order syringes for tomorrow Methadone prefill. VN left 1 syringe prefilled to be administer by caregiver." The Hospice Coordination Notes -AHS Inbound Triage Call dated 1/19/2022 6:42 PM (time of call) documents: "911 activation;" aide (non-hospice aide) "activated 911 due to the pt having SOB (shortness of breath) and foaming in the mouth. Pt is unresponsive." The Hospice Physician GIP (General Inpatient) Collaboration Note dated 1/20/2022 documents: "There are uncontrolled symptoms requiring intensive physician/nursing intervention. Patient is a 70 YO female with Hospice diagnosis of Endometrial CA, related Asthma and Emphysema with uncontrolled dyspnea despite home intervention;" "GIP LOC (level of care) medically necessary for symptom management of dyspnea." There is no evidence that the hospice ensured that the patient was able to start nebulizer treatment and take pain medication as ordered. On 2/10/2022 at 4:10 PM, the Hospice Director of Quality was interviewed, and there was no additional information provided for the survey findings. 3. Patient #2 has a hospice admission date of 12/14/2021 with terminal diagnosis of Malignant Neoplasm of Pyloric Antrum as documented on the hospice plan of Care (POC) dated 12/14/2021 to 3/13/2022. The Hospice Coordination Notes - Incoming Call Note dated 1/3/2022 9:48 AM (time of call) document: "Spouse claims pt (patient) may have pneumonia/wheezing. Call connected." The Hospice Coordination Notes RN (Registered Nurse) Narrative dated 1/3/2022 (no time) document: "Received a call form pt spouse (name). As per (spouse), Pt SPO2 74%. (spouse) expressed she is a nurse and believes pt may have aspiration pneumonia. Pt heard in back with loud audible gurgling. As per spouse no fever just low SPO2 and change in respirations. Spouse verbalized she removed Fentanyl patch as she feels the medication is causing too much sedation. This (nurse) instructed caregiver to administer 1 dose of Morphine 0.25ml (milliliter) to help with current symptoms pt is experiencing. This CS (Clinical Supervisor) reached out to team to assign RN; (Name of RN) for visit." The Hospice Coordination Notes - Incoming call Message Left dated 1/3/2022 12:14 PM (time of call) document: "Call note Patient spouse (name) - I spoke with supervisor (name) earlier. I am taking him (patient) to the hospital. I am calling to cancel hospice. That's it I just want to tell her that." The Hospice Coordination Notes -Healthix Alert Note dated 1/3/2022 documents: "Alert received from (hospital); admit date 01/03/2022 12:06 PM; Event Type: ED (emergency department) Admit; Diagnosis: Severe Diff (Difficulty) Breathing." The Hospice Coordination Notes -Healthix Alert Note dated 1/3/2022 document: "Admit Date 01/03/2022 12:41PM; Event Type: ED Admit; Diagnosis R06.02 Shortness of Breath." There is no documented evidence of timely follow-up to report of respiratory distress efforts to determine the status of the patient's symptoms after the initial call and recommendation for treatment. There is no documented evidence that patient's spouse was informed of the nurse's estimated time of arrival to address the patient's pain and symptoms. The hospice failed to provide a timely response to manage the patient's symptoms of pain and distress. The hospice failed to provide timely RN visit, failed to provide RN ETA (estimated time of arrival) to the patient and spouse, and failed to follow-up on the request for urgent assistance to address Patient #2 symptoms of respiratory distress. On 2/10/2022 at 4:10PM, the Hospice Director of Quality was interviewed, and there was no additional information was provided for the survey findings. 4. Patient #16 has a hospice admission date of 12/26/2021 with diagnosis of Alzheimer's Disease, Unspecified as documented on the hospice plan of Care (POC) dated 12/26/2021 to 3/25/2022. The Hospice Coordination Notes dated 1/12/2022 documents the following: 11:02PM (Time of Initial Call) - Hospice AHS Inbound Triage Call Note: "Pt son stated patient fell. Pt was found on the bathroom fall (floor). Pt son stated he does not know if patient hit her head. No head injuries reported. Pt reported bruising and a lump on the right leg. Pt son is concerned the patient leg might be broken." "Assessment: Advise to take Tylenol for the pain. Requesting nursing visit for post fall and to assess. Pain scale: Patient's Pain (Scale 1 least 10 greatest) rating: 8. Recommendation: Plan is to request a nursing visit for post fall and to assess." 11:26PM Hospice Urgent Visit Request for After Hours: "Urgent Request Reason: Post fall and patient has lump on the right thigh." Assigned to SN (Skilled Nurse) (name). The Hospice Coordination Note - AHS (After Hours Supervisor) Visit Follow-up Note dated 1/13/2022 documents: "I talked to (patient's son) at 12:35AM, ETA (estimated time of arrival) 1:30AM." The Hospice SN Visit Note dated 1/13/2022 1:34AM (In-home began time) documents: "Patient is observed in hospital bed. Vital signs stable. Right leg seems to be fractured. The right thigh is very swollen and painful on touch and movement and right leg is shorter then (than) the other leg. Patient is able to move the left leg, but not right one. MD (Medical Doctor) (name) was called. She said she already say patient has to go the ER (Emergency Room)." "I talked with (After Hours Supervisor) whom asked patient son to call 911. EMS (Emergency Medical Services) came shortly." The Hospice AHS Coordination Notes dated 1/13/2022 1:56AM document: "Collaborated with Dr. (name) regarding patient s/p (status post) fall. Stated from conversation with LPN (Licensed Practical Nurse) (name) right leg fracture suspected. Recommendation have patient go to ER for X-Ray or order to call 911 or activate Paramedicine." The Hospice AHS Post Triage Follow-up Call Coordination Note dated 1/13/2022 1:48AM (time of initial call) documents: "Informed son that Dr. (name) recommendation that patient be taken to ER for X-ray for suspected right hip fracture. Son agree to take patient to ER." The Hospice AHS Post Triage Follow-up Call Coordinator Note dated 1/13/2022 3:45AM (time of call) documents: "Coordinated with son (name):" Patient "admitted to (name) Hospital, broken right femur. Son stated that the hospital plan is to place (patient) into fraction (traction) and perform surgery. He is in agreement of hospital plan." The clinical record documents that the hospice took approximately two and half hours (from 1/12/2022 11:02PM (initial call) to 1/13/2022 1:34AM (SN home visit)) to respond to a patient with a fall, possible fractured leg and pain level of 8 out of 10 post fall. The Hospice failed to provide a timely and appropriate response to a report of a patient fall and possible leg fracture, with pain and bruising. The Hospice failed to assess patient for pain. On 2/16/2022 at 3:00PM, the Hospice Director of Quality Management Services was interviewed, and stated the hospice "Should have called Paramedicine/EMS (Emergency Medical Services)" to immediately respond.

2. Patient #14 has a Start of Care date of 6/10/2021 with the following diagnoses "Chronic Myeloproliferative Disease, Unspecified Protein-Calorie Malnutrition, Unspecified Dementia without Behavioral Disturbance" documented in the Hospice Certification and Plan of Care dated 6/10/2021 to 9/7/2021. A home visit was conducted on 10/19/2021 at 12:40pm with Patient #14, the Paraprofessional Plan of Care dated 9/8/2021, lacks documented evidence of the frequency of the tasks. The Aide Care Plan Report Start of Episode on 9/8/2021 print-out lacks documented evidence of the frequency of the tasks. There is no documented evidence of a complete Aide's Plan of Care. On 10/20/2021 at 3:40pm, the Director of Quality Management Services and Clinical Director of Hospice were interviewed and did not provide an explanation for the findings. Based on clinical record review and staff interview the hospice failed to ensure that all Hospice Aides received complete written patient care instructions prepared by a Registered Nurse (RN). This is evident for two (2) of eleven (11) clinical records reviewed for patients receiving hha services (Patient #2, and #14). Failure to ensure all Hospice Aides receive complete written patient care instructions prepared by a Registered Nurse (RN) has the potential for negative outcomes. The Findings are: 1. Patient #2 has a Start of Care date of 08/11/2021 with the following diagnoses "Malignant Neoplasm of Esophagus, Dysphagia, Oropharyngeal Phase, Barrett's Esophagus with Dysplasia" documented on the Hospice Certification and Plan of Care dated 08/11/2021 to 11/08/2021. The Hospice Certification and Plan of Care dated 08/11/2021 to 10/08/2021 documents: "HHA (Hospice Aide) 08/09/2021 2WK1 (two days a week for one week), 5WK12 (five days a week for twelve weeks), 1WK1 (one days a week for one week). The Paraprofessional Plan of Care (print-out) lacks documented evidence of the tasks frequency. There is no documented evidence of the aide's written Plan of Care being complete. On 10/22/2021 at 10:30 am, the Director of Quality Hospice, Senior Vice President Hospice and Clinical Director were interviewed and did not provide an explanation for the findings.