Every finding on record at Vistacare USA, LLC

Upon patient record review, 1 of 5 (Patient #1) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 1: The medical record contained nursing documentation 11/18/25 identifying RN completed treatment applying compression wrap to right lower extremity. There was no evidence of further documentation regarding continued treatment.

Upon patient record review, 1 of 5 (Patient #4) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 4: The medical record contained nursing documentation upon admission identifying patient history of seizures. There was no evidence of problems, goals, and interventions related to risk of seizures included in the plan of care. Corrected on site with plan of care update.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 1: The medical record contained nursing documentation upon recertification assessment 11/18/25 regarding patient use of a C-PAP. There was no evidence of an order for C-PAP parameters. Corrected on site with order clarifications.

Upon patient record review, 2 of 5 (Patients #1,#2) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 1: The medical record contained nursing documentation upon recertification assessment 11/18/25 regarding patient use of a C-PAP, rollator, cane, and shower chair. There was no evidence of orders for the DME included in the plan of care. Corrected on site with orders received. Patient 2: The medical record contained nursing documentation upon recertification assessment 11/13/25 identifying patient use of a commode. There was no evidence of an order for the commode included in the plan of care. Corrected on site with order received.

Upon client record review, 1 of 5 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: The medical record contained nursing documentation 11/18/25 identifying RN completed treatment applying compression wrap to right lower extremity. There was no evidence of an order for the treatment.

Upon client record review, 1 of 5 (Patient #3) did not have evidence that the physician provides a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the recertification form, or as an addendum to the recertification form. Patient 3: The written explanation of eligibility on the Certification of Terminal Illness upon admission for patient transferred from another hospice agency during benefit period 11 contained information for the wrong patient with similar name.

Upon observation, there was no evidence the organization follows their policies and procedures to maintain the the patient's clinical record in confidential manner. Patient 3: The written explanation of eligibility on the Certification of Terminal Illness upon admission for patient transferred from another hospice agency during benefit period 11 contained information for the wrong patient with similar name.

Upon patient record review 6 of 19 (Patient #2,4,6,7,9,12) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 2: No evidence that the spiritual assessment was completed within 5 days of admission. The patient was admitted on 6/01/24. The spiritual care assessment was completed on 9/23/25. Patient 4: No evidence that the spiritual assessment was completed within 5 days of admission. The patient was admitted on 5/2/25. The spiritual care assessment was completed on 8/18/25. Patient 6: No evidence that the spiritual assessment was completed within 5 days of admission. The patient was admitted on 1/23/25. The spiritual care assessment was completed on 8/18/25. Patient 7: No evidence that the spiritual assessment was completed within 5 days of admission. The patient was admitted on 7/14/24. The spiritual care assessment was completed on 8/18/25. Patient 9: No evidence that the spiritual assessment was completed within 5 days of admission. The patient was admitted on 7/13/24. The spiritual care assessment was completed on 9/28/25. Patient 12: No evidence that the spiritual assessment was completed within 5 days of admission. The patient was admitted on 5/08/25. The spiritual care assessment was completed on 9/30/25.

Upon patient record review, 1 of 19 (Patient #5) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 5: Current medication list includes 2 entries for PRN oxygen. Both instructed to be given via nasal cannula and to be used for dyspnea. One was ordered on 09/02/2025 at 2L per minute, the other was ordered on 09/03/2025 at 2-3L per minute. No evidence that instructions were given on when to use either PRN order. Corrected on site. Clarification order placed during survey.

Upon patient record review, 6 of 19 (Patient #3,5,6,7,10,14) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 3: No evidence that the initial bereavement assessment was completed within 5 days of election of hospice. The patient was admitted on 08/28/2024. The bereavement risk assessment was completed on 09/04/2024. Patient 5: No evidence that the initial bereavement assessment was completed within 5 days of election of hospice. The patient was admitted on 6/19/2025. The bereavement risk assessment was completed on 6/30/2025. Patient 6: No evidence that the initial bereavement assessment was completed within 5 days of election of hospice. The patient was admitted on 1/23/2025. The bereavement risk assessment was completed on 1/30/2025. Patient 7: No evidence that the initial bereavement assessment was completed within 5 days of election of hospice. The patient was admitted on 07/14/2024. The bereavement risk assessment was completed on 07/23/2024. Patient 10: No evidence that the initial bereavement assessment was completed within 5 days of election of hospice. The bereavement coordinator documented that the patient did not have any bereavement needs on day 7 following the election of hospice. Patient 14: No evidence that the initial bereavement assessment was completed within 5 days of election of hospice. The patient was admitted on 11/07/2024. The bereavement risk assessment was completed on day 6 following the election of hospice.

Upon patient record review, 2 of 19 (Patient #8,12) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 8: No evidence that a RN comprehensive assessment was completed every 15 days between 07/17/2025 and 08/04/2025, 18 days between comprehensive assessments. Patient 12: No evidence that a RN comprehensive assessment was completed every 15 days between 09/26/2025 and 10/14/2025, 18 days between comprehensive assessments.

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

Upon patient record review, 1 of 19 (Patient #12) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 12: The record indicated that a call came through triage on 7/05/25 at 0905am from the patient's home. The patient's family was reporting that the patient bilateral upper and lower limbs were flaccid and they were having a hard time arousing her. Triage indicated a need for a visit and that a message was sent to the on-call nurse for follow up visit. There was not an indication of follow up assessment until 07/08/25. That visit was completed by the LPN. No evidence that the follow-up assessment was completed.

Upon patient record review, 2 of 19 (Patient #3,4) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 3: The medical record indicated that the patient refused chaplain services after initial visit. Currently patient is in the 15th benefit period with problems, interventions, and goals related to spiritual care on the plan of care. Corrected on site - plan of care updated to include depression during survey. Patient 4: The medical record indicated that the patient has Down syndrome and Cerebral Palsy. No evidence of problems, goals, and interventions related to neurological deficit included in the plan of care. Corrected on site - plan of care updated to include neurological chapter updated during survey.

Upon patient record review, 4 of 19 (Patient #5,7,9,13) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 5: Current medication list includes 2 entries for PRN oxygen. Both instructed to be given via nasal cannula and to be used for dyspnea. One was ordered on 09/02/2025 at 2L per minute, the other was ordered on 09/03/2025 at 2-3L pr minute. No evidence that instructions were given on the orders to tell when to use either PRN. Corrected on site - clarification order written during survey. Patient 7: RN documentation indicated that the patient uses oxygen at 10LNC continuously. No evidence that an order was received for oxygen continuously at 10L via NC. The current oxygen order is for 5L continuously via NC. Corrected on site - New order written during survey. Patient 9: RN documentation indicated that the patient uses oxygen at 7LNC continuously and CPAP at night. No evidence that an order was received for oxygen continuously at 7LNC or CPAP setting. The current oxygen order is for 8L continuously via NC. Corrected on site - New orders written during survey. Patient 13: RN documentation indicated that the patient uses oxygen at 4.5LNC, 5LNC, and 6LNC continuously and CPAP at night. No evidence that an order was received for oxygen at 4.5L, 5L, or 6L NC or CPAP setting. The current oxygen order is for 8L continuously via NC. Corrected on site - New orders written during survey.

Upon patient record review, 4 of 19 (Patient #10,11,12,13) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 10: The medical record indicated that the patient uses a Hoyer lift for safe transfers. No evidence that a Hoyer was included on the current DME supply list. Corrected on site - new orders received to update the supply list during survey. Patient 11: The RN documented that the patient had a hospital bed and 1/2 length bed rails delivered on 09/14/25. No evidence that hospital bed or bed rails were included on the current DME supply list. Corrected on site - new orders received to update the supply list during survey. Patient 12: The medical record documented that the patient uses a rollator for altered mobility. No evidence that rollator was included on the current DME supply list. Corrected on site - new orders received to update the supply list during survey. Patient 13: The current DME supply list included catheter supplies. No evidence that the patient had a catheter during time on service. Corrected on site - new orders received to update supply list during survey.

Upon patient record review, 2 of 19 (Patient #8, 14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 8: Plan of care has SN visits ordered as twice weekly. No evidence that the patient received 2 visits for the week of 08/31/2025. No evidence that the visit was missed at the request of the patient or the caregiver. Patient 14: The medical record indicated that chaplain services were declined and were removed from the current benefit periods POC on 08/20/2025 however the chaplain continued to complete visits with the patient for the months of September and October 2025.

Upon patient record review 3 of 19 (Patient #1,4,10) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 1: The plan of care had aide frequency ordered as twice a week. No evidence that 2 visits were completed for the week of 08/31/25 and 10/06/25. Only one visit documented for the week 08/31/25, that visit occurred on 09/04/25. One visit documented for the week of 10/06/25, that visit occurred on 10/09. Patient 4: The plan of care had the aide frequency ordered as 3 times a week. No evidence that 3 visits occurred for the week of 08/31/2025. Only 2 visits documented for that week, visits occurred on 09/02, 09/05. Patient 10: The plan of care had aide frequency ordered as twice a week. No evidence that 2 visits were completed for the week of 08/31/2025. Only one visit documented for that week, that visit occurred on 09/04/2025.

Upon patient record review 1 of 19 (Patient #3) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 3: No evidence that a registered nurse made an aide supervisory visit every 14 days between 08/04/25- 08/25/25 (21 days).

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The total usage of volunteers for 2024 was 0.6%

Upon observation and patient record review, 5 of 19 (Patient #1,3,4,5,6), there was no evidence the hospice is primarily engaged in providing the following care and services: • Nursing services • Medical social services • Physician services • Counseling services, including spiritual counseling, dietary counseling and bereavement counseling • Hospice aide, volunteer, homemaker services • Physical therapy, occupational therapy, speech-language pathology services • Short-term inpatient care • Medical supplies (including drugs and biologicals) and medical appliance Patient 1,3,4,5,6: Medical record indicated that the LPN had edited an intervention in the respiratory chapter of the plan of care.

Condition of Participation: Medical Director.

Upon patient record review, 10 of 19 (Patient #1,2,3,4,5,6,7,10,13,14) did not have evidence that there is a physician's brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the certification forms, or as an addendum to the certification forms. Patient 1,2,3,4,5,6,7,10,13,14: Initial CTI narrative written by the medical director was an exact copy of the RN admission IDG narrative.

Upon patient record review, 11 of 19 (Patient #1,2,3,4,5,6,7,10,12,13,14) did not have evidence that the physician provides a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the recertification form, or as an addendum to the recertification form. Patient 1,2,3,4,5,6,7,10,12,13,14: Recert CTI narratives written by the medical director were an exact copy of the RN recert IDG narratives.

Based on record reviews and interview, the agency failed to maintain documentation of the services it would provide during an emergency and failed to identify the individuals in the emergency succession plan, affecting 1 of 1 agency reviewed. Findings include: --- 1. A 01/06/2023 policy titled "Emergency Management Plan" indicated the agency's emergency plan will include the identification of roles, responsibilities, and community resources. 2. The Emergency Preparedness 2024 binder evidenced a form titled "Plan to Stay in Business." The agency failed to complete the form. The agency failed to plan for continuing operations during an emergency or a written delegation of command. 3. During an interview on 02/07/2024, the Administrator indicated they were new to their position and had not looked at the 2024 Emergency Preparedness Binder. The Administrator indicated they placed the agency's patient face sheets, a list of personnel, personnel contact information, and a phone tree in the binder during the survey. They were unaware the other documents in the emergency preparedness binder were incomplete. They indicated the services the agency would provide during an emergency would depend on the event's severity and the patient's priority. The Emergency Preparedness plan failed to identify the individuals in the emergency succession plan.

Based on record review and interview, the agency failed to include a communication plan identifying the contact information for Federal, State, Tribal, Regional, and Local emergency preparedness staff for 1 of 1 emergency preparedness plans reviewed. Findings include: --- 1. The Emergency Preparedness 2024 binder evidenced an incomplete document titled "other contacts" and an incomplete document titled "Plan to Coordinate with Others." 2. During an interview on 02/07/2024, the Administrator indicated they were new to their position and had not looked at the 2024 Emergency Preparedness Binder. The Administrator indicated they placed the agency's patient facesheets, a list of personnel, personnel contact information, and a phone tree in the binder during the survey. They were unaware the other documents in the emergency preparedness binder were incomplete.

Based on record review and interview, the agency failed to have written instructions on sharing patient-sensitive information with other individuals not employed by the agency during an emergency, affecting 1 of 1 emergency preparedness plan. Findings include: --- 1. Documents from the "Emergency Preparedness 2024" binder and "Emergency Management Plan Policy" failed to address how the agency would share patient information with other individuals not employed by the agency. 2. During an interview on 02/07/2024 at 10:30 AM, the Patient Care Manager indicated during an emergency, the agency would require patients' date of birth and other identifiers before patient information would be released to individuals not employed by the agency; if with other facility/agency would need to look at contract to determine if patient information could be shared.

Based on observation, record review, and interview, the agency failed to complete an initial assessment within 48 hours of receiving a referral (see tag 522); the agency staff failed to perform a complete comprehensive physical assessment (see tag 524); the agency failed to ensure that the comprehensive assessments were updated to include consistent and accurate assessments of skin impairments/wounds that had been identified and measured weekly per agency policy (see tag 533). An Immediate Jeopardy related to Condition of Participation §418.54: Initial and Comprehensive Assessment of the Patient was identified and announced on 02/06/2024 09:40 AM. The agency's immediate jeopardy abatement plan and actions were determined to have removed the immediacy component of the Immediate Jeopardy on 02/12/2024. --- The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality of care in a safe environment for the Condition of Participation §418.54: Initial and Comprehensive Assessment of the Patient.

Based on record reviews and an interview, the agency failed to complete an initial assessment within 48 hours of receiving a referral for 5 of 14 records reviewed. (Patient #2, #8, #10, #12, #19). Findings include: --- 1. The clinical record for Patient #2 included a Patient information Report that indicated a referral date of 12/13/2023 and an Episode Summary Report that indicated the Start of care date of 12/19/2023. The record failed to evidence documentation indicating a reason for the delay in the initial assessment. 2. The clinical record for Patient #8 included a Patient information Report that indicated a referral date of 12/06/2023 and an Episode Summary Report that indicated the Start of care date of 12/11/2023. The record failed to evidence documentation indicating a reason for the delay in the initial assessment. 3. The clinical record for Patient #10 included a Patient information Report that indicated a referral date of 04/03/2023 and an Episode Summary Report that indicated the Start of care date of 04/ 06/2023. The record failed to evidence documentation indicating a reason for the delay in the initial assessment. 4. The clinical record for Patient #12 included a Patient information Report that indicated a referral date of 11/10/2023 and an Episode Summary Report that indicated the Start of care date of 11/15/2023. The record failed to evidence documentation indicating a reason for the delay in the initial assessment. 5. The clinical record for Patient #19 included a Patient information Report that indicated a referral date of 11/22/23 and an Episode Summary Report that indicated the Start of care date of 11/27/2023. The record failed to evidence documentation indicating a reason for the delay in the initial assessment. 6. During an interview on 02/12/2024, the Admission Coordinator indicated they put referrals in Homecare Homebase (computer system used for documentation) and provided a daily email to all staff, reporting patients who have been referred but not admitted; this report is populated on an Excel worksheet and reviewed daily during morning meeting. They indicated there is a place to document why the initial assessment is delayed, but not everyone enters the reason, and it does not show on patient clinical record documentation.

Based on observation, record review, and interview, the agency staff failed to perform a complete comprehensive physical assessment for 8 of 10 record reviews with patients with wounds/skin integrity issues. (Patients #4, #7, #12,#13 #14, #15, #18 #20) Findings include: --- 10. A review of the skilled Visit Notes for Patient #4 evidenced a Stage II pressure ulcer to the coccyx with an onset date of 12/15/2023. The comprehensive skilled Visit Notes failed to evidence weekly wound measurements for 12/27/2023. 11. A review of the skilled Visit Notes for Patient #7 evidenced a stage II pressure ulcer to the right lower buttock with an onset date of 10/31/2023, a stage II pressure ulcer on the left buttock with an onset date of 12/05/2023, a stage II pressure ulcer right lower leg with an onset date of 12/11/2023 and an arterial ulcer left lower leg with an onset date of 12/19/2023. The comprehensive skilled Visit Notes failed to evidence weekly wound measurements for 01/10/2024. 12. A review of the skilled Visit Notes for Patient #12 evidenced a full-thickness trauma to the ischium with an onset date of 12/14/2023. The comprehensive skilled Visit Notes failed to evidence weekly wound measurements for 12/20/2023 and 01/03/2024. 13. During an observation on 02/02/2024, LPN 3 assessed the skin of Patient #12s left shoulder blade and left upper chest, which had multiple areas in different stages of healing due to an outbreak of shingles. No measurements were taken during the visit, and no documentation of either area was found in the patient's wound record report. The comprehensive skilled Visit Notes failed to evidence weekly wound measurements for 02/07/2024. 14. A review of the skilled Visit Notes for Patient #18 evidenced a Stage II pressure ulcer to the coccyx with a reactivated date of 11/07/2023 and a Superficial Traumatic sacral injury with an onset date of 01/05/2024. The comprehensive skilled Visit Notes failed to evidence weekly wound measurements for 01/31/2024. 15. During an interview on 02/02/2024 at 10:55 AM, LPN 3 indicated wounds are to be assessed every visit and measurements are to be taken weekly; there is no reason for either not to be done unless the patient refuses for that visit. 1. A policy titled "Comprehensive Assessment" was provided by the Administrator on 02/05/2024. The policy indicated that during the comprehensive patient assessment, all baseline data and other relevant information would be documented in the clinical record, including current treatment and patient response to that treatment, a physical assessment that includes all relevant information, complications, individualized patient care needs, and data elements for the measurement of outcomes. 2, A Registered Nurse (RN) job description was provided by the Administrator on 01/31/2024, which indicated the RN was to provide direct patient care, evaluate patient needs, and professional management of each patient. 3. A policy titled "Wound Assessment, Documentation, and Clinical Oversight" was provided by the Administrator on 02/01/2024. The policy indicated the Registered Nurse was to perform wound care no less than once a week. The RN was to measure (length, width, depth) of the wounds at least once a week and report changes to the physician. The nurse was to document wound care and treatment, every dressing change, and the patient's response to each treatment. 4. During a home visit on 02/02/2024, Patient #13 was given a bed bath by CNA 2. CNA 2 stated the crease of the buttocks was deep red and with ragged asymmetrical open areas to the right and left buttocks. The CNA said the buttocks were redder than the previous visit, and the open areas were new. Three dry red areas were found on Patient 13's left leg and foot. A review of the comprehensive skilled Visit Notes for Patient #13 failed to evidence A phone interview was conducted on 02/02/2024 with Patient #13s daughter, who stated the patient had red areas on the left lower leg/foot and no one knew how they got there and was told that was part of the dying process. 5. A review of the comprehensive skilled Visit Notes for Patient #14 evidenced a Stage II second left toe wound with an onset date of 12/29/2023. The comprehensive skilled Visit Notes failed to evidence weekly wound measurements for 01/18/2024 and 01/13/2024. 6. A review of the comprehensive skilled Visit Notes for Patient #15 evidenced redness to the coccyx (tailbone) or buttocks with an onset date of 01/23/2024.The comprehensive skilled Visit Notes failed to evidence weekly wound measurements/skin integrity changes from 01/23/2024 to 02/01/2024. 7. A review of the comprehensive skilled Visit Notes for Patient #20 evidenced a Stage IV iliac crest wound with an onset date of 10/10/2023. The comprehensive skilled Visit Notes failed to evidence weekly wound measurements for 01/10/2024, 01/19/2024, and 01/26/2024. 8. On 02/05/2024, the Administrator stated that staff are to discuss if the patients with wounds are progressing in healing. Staff should be assessing wounds every visit, even if wound care has already been done. Staff should be rolling patients over to evaluate the entire backside. Wounds are to be measured/assessed weekly, along with redness. 9. On 02/05/2024, the Medical Director stated the expectation was for staff to discuss the length, width, depth, and treatment for patients with wounds and any skin issues at each IDG meeting. Staff are to discuss interventions to prevent more wounds, progress toward healing, and if the patient met the goal.

Based on observation, record review, and interview, the agency failed to ensure that the comprehensive assessments were updated to include consistent and accurate assessments of skin impairments/wounds that had been identified and measured weekly per agency policy for 8 of 10 records reviewed (Patient #4, #7, #12, #13, #14, #15, #18, #20) which had the potential to affect all 120 active patients. Findings include: --- 5. A review of the skilled Visit Notes for Patient #4 failed to evidence wound measurements and assessments for the Stage II coccyx wound for visit 12/16/2023, 12/21/2023, and 12/28/2023. 6. A review of the skilled Visit Notes for Patient #7 failed to evidence wound measurements for a stage II pressure ulcer to left buttock, a stage II pressure ulcer right lower leg 2023 and an arterial ulcer left lower leg for visits 01/09/2024,01/10/2024, 01/12/2024, and 01/15/2024. 7. A review of the skilled Visit Notes for Patient #12 failed to evidence wound measurements for full thickness trauma to the ischium wound for visit 12/14/2023, 12/21/2023, 12/28/2023, and 01/04/2024. 8. A review of the skilled Visit Notes for Patient #18 failed to evidence wound measurements for Stage II pressure ulcer to coccyx for visit 02/08/2024, and a Superficial Traumatic sacral injury for visit 01/08/2024, 01/16/2024, 01/19/2024, 01/21/2024, 02/23/2024, 01/25/2024, 01/30/2024. 9. During an interview on 02/02/2024 at 10:55 AM, LPN 3 indicated wounds are to be assessed every visit and measurements are to be taken weekly; there is no reason for either not to be done, unless patient refuses for that visit. 1. A policy titled "Wound Assessment, Documentation, and Clinical Oversight" was provided by the Administrator on 02/01/2024. The policy indicated the Registered Nurse was to perform wound care no less than once a week. The RN was to measure (length, width, depth) of the wounds at least once a week and report changes to the physician. The nurse was to document wound care and treatment, every dressing change, and the patient's response to each treatment. 2. A review of the comprehensive skilled Visit Notes for Patient #14 failed to evidence wound measurements for the Stage II second left toe wound for 01/18/2024 and 01/13/2024. 3. A review of the comprehensive skilled Visit Notes for Patient #15 failed to evidence measurements of any redness to the coccyx (tailbone) or buttocks for 01/23/2024 to 02/01/2024. 4. A review of the comprehensive skilled Visit Notes for Patient #20 failed to evidence wound measurements for a Stage IV iliac crest wound for 01/10/2024, 01/19/2024, and 01/26/2024.

Based on record review and interview, the hospice failed to ensure that the updated comprehensive assessment included progress toward outcomes and goals for 6 of 20 records reviewed. (Patient #2, #4, #7, #12, #14, #15) Findings include: --- 4. The clinical record for Patient #2, benefit period 12/19/2023 to 03/17/2024, included start of care nursing visit dated 12/19/2023 that indicated patient #2 was being treated for UTI, is at risk for skin break down due to being incontinent. The Client Medication report list indicated the patient completed the final Cipro (antibiotic) dose on 12/26/2023. A review of an IDG Comprehensive Assessment and Plan of Care Update Report dated 12/27/2023 indicated patient #2 was still being treated for UTI; the medication list shows it was discontinued on 12/26/2023 due to not being approved, RN 10 indicated not identifying any problems during the initial evaluation and no plan identified for the next two weeks. A visit note report dated 01/05/2024 indicated patient #2 was moaning out with anxiety; Lorazepam (used for restlessness/agitation) was given. A review of an IDG Comprehensive Assessment and Plan of Care Update Report dated 01/10/2024 indicated five non-resolved problems. The report also indicated the home health aide frequency was changed on 01/05/2024 from twice a week to once per week. RN 10 reported the patient is at risk for skin breakdown; no noted reason for the home health aide visit frequency change, or for Lorazepam started due to the patient's actions. Problems, interventions, and goals identified: No skin breakdown or infections for the next two weeks. A review of an IDG Comprehensive Assessment and Plan of Care Update Report dated 01/17/2024 indicated five non-resolved problems and no discussions on the progress of the patient's skin condition or signs and symptoms of infection. The Care Plan shows no problems resolved; problems, interventions, and goals identified: No skin breakdown for the next two weeks—no progress reported on medication helping patient's outburst, skin condition, or infection. During an IDG meeting on 01/31/2024, the IDG members did not discuss progress, goals, or the patient's response regarding symptom management. 5. The clinical record for Patient #4, benefit period 12/15/2023 to 03/13/2024, included a Visit Note report dated 12/15/2023, indicates a stage II pressure ulcer to the coccyx, no wound care orders, no wound measurements, and no wound assessment completed during a visit by RN 2. Documentation indicates wound care completed by the caregiver. A visit note report dated 12/21/2023 indicates a stage II pressure ulcer to the coccyx. No wound care orders were noted, no wound measurements were made, and no wound assessment was completed during the visit by RN 3. Documentation indicates wound care completed by the caregiver. The narrative note, included in the Visit Note Report, noted that the patient had increased shoulder pain; Norco changed to routine medication, and a stool softener was added. A review of an IDG Comprehensive Assessment and Plan of Care Update Report dated 12/27/2023 indicated no discussion of wound measurements or any progress on healing to stage II pressure ulcer on the coccyx and indicates Patient #4 developed a stage II pressure ulcer to right heal. There was no discussion of wound care being provided or request for wound care orders for either wound. There was no discussion regarding the effect of the new prescription of pain medication to help manage shoulder pain or the effects it had on patients' stool production. A visit note report dated 12/28/2023 completed by RN 1 indicates a stage II pressure ulcer to the coccyx is healed, with no assessment conducted. A visit note report dated 12/29/2023 completed by RN 1 indicated the visit was made due to a patient having increased confusion, and no new treatments were noted. A review of an IDG Comprehensive Assessment and Plan of Care Update Report dated 01/10/2024 indicated no goals had been resolved for Patient #4 since 12/16/2023, wound care supplies were added to the Plan of care, with no wound care being provided, no discussion of the wound to coccyx or right heal being healed, or patient having increased confusion. RN 1 indicated problems, interventions, and goals for next two weeks are symptom management, family and facility education and support. A review of an IDG Comprehensive Assessment and Plan of Care Update Report dated 01/17/2024 indicated no goals have been resolved for patient #4. RN 1 indicated problems, interventions, and goals for the next two weeks: symptom management, family and facility education, and support. During an IDG meeting on 01/31/2024, the IDG members did not discuss progress, goals, or the patient's response regarding symptom management. 6. The clinical record for Patient #7, benefit period 01/04/2024 to 01/16/2024, included a skilled Visit Note dated 01/09/2024 that indicated a stage II pressure ulcer to the right lower buttock, a stage II pressure ulcer left buttock, a stage II pressure ulcer right lower leg and an arterial ulcer left lower leg. A review of an IDG Comprehensive Assessment and Plan of Care Update Report dated 01/10/2024 indicated six goals that were unsolved since 10/08/2023; RN 11 did not provide any information regarding wounds to the right or left buttock; the bilateral lower extremity wounds were mentioned of wound care provided, no detailed information regarding condition of wound or measurements provided. 7. The clinical record for Patient #12, benefit period 11/15/2023 to 02/12/2024, included a Visit Note report dated 12/11/2023 that indicated a full-thickness trauma to the ischium A review of an IDG Summary Report dated 12/13/2023 did not indicate Patient #12 had a wound to the ischium. There was no discussion of wound measurements, treatment provided, progress on healing, or outcomes. A review of an IDG Summary Report dated 12/20/2023 indicated that foam dressing for preventative measures against coccyx was added to supplies. There was no discussion of wound measurements, treatment provided, progress on healing, or outcomes. A review of an IDG Summary Report dated 01/03/2024 indicated no discussion of wound measurements, treatment provided, progress on healing, or outcomes. A review of the Visit note report dated 01/04/2024 that indicated a full-thickness trauma wound to ischium was healed. A review of an IDG Summary Report dated 01/10/2024 indicated no discussion of wound measurements, treatment provided, progress on healing, or outcomes. A review of the Visit note report dated 01/11/2024 indicated that the patient has shingles rash on the left upper chest radiating into the left axilla and left scapula, and the area has small fluid-filled sac and scabbed over lesions. A review of an IDG Summary Report dated 01/24/2024 indicated no discussion of shingle rash/wound measurements, treatment provided, progress on healing, or outcomes. During an IDG meeting on 01/31/2024, the IDG members did not discuss progress, goals, or the patient's response regarding symptom management. A review of the visit note report dated 02/02/2024 indicated the patient has a rash of shingles on the left upper chest and left upper back. A review of the IDG Comprehensive Assessment and Plan of Care Update Report dated 02/07/2024 indicated no discussion of shingle rash/wound measurements, treatment provided, progress on healing, or outcomes. During an observation on 02/02/2024, LPN 3 evaluated shingles rash/wounds to the left upper chest and left shoulder blade; no measurements were taken during the visit. The caregiver indicated the area was being treated with Calamine lotion (Used to treat mild itchiness). There were no wound orders for rash were noted in the clinical chart. 8. During an interview on 02/02/2024 at 4:16 PM, the Administrator indicated that patient skin assessment should be done every visit; this includes rolling the patient over and evaluating their backside; red areas should be measured and evaluated to monitor the progress of healing. 1. A policy titled "Comprehensive Assessment" was provided by the Administrator on 02/05/2024. The policy indicated that during the comprehensive patient assessment, all baseline data and other relevant information would be documented in the clinical record, including current treatment and patient response to that treatment, a physical assessment that includes all relevant information, complications, individualized patient care needs, and data elements for the measurement of outcomes. 2. The clinical record for Patient #14, election date 12/16/2023, benefit period 12/13/2023 to 02/10/2024, included skilled Visit Notes dated 12/01/2023 that indicated wounds to the left hand and a stage II pressure ulcer on the left 2nd toe. A review of an IDG Comprehensive Assessment and Plan of Care Update Report dated 12/13/2023 indicated Patient #14 was on an antibiotic for an infection to the left second toe. There was no discussion of wound measurements or progress on healing or outcomes. There was no documentation of the patient's response to care regarding the treatment. A review of an IDG Comprehensive Assessment and Plan of Care Update Report dated 12/20/2023 indicated no discussion of wound measurements or any progress on healing. A review of an IDG Comprehensive Assessment and Plan of Care Update Report dated 01/03/2024 indicated Patient #14 developed a stage II wound to the left 2nd toe and had a fall resulting in 9 steri-strips to the forehead. There was no documentation of any progress on healing or outcomes. A review of an IDG Comprehensive Assessment and Plan of Care Update Report dated 01/17/2024 indicated Patient #14 had a stage II wound to the left 2nd toe. No discussion of wound measurements or any progress on healing. During an IDG meeting on 01/31/2024, the IDG members did not discuss any progress, goals, or the patient's response regarding Patient #14's stage II wound to the left 2nd toe. The problems, interventions, and goals to be addressed in the next two weeks include Alzheimer's activities, fall mat/low bed/ pommel cushion/dycem (already in place), and remaining free of falls, pain, and communication. At the meeting, there was no discussion of a specific goal that would be measurable, attainable, relevant, and time-bound for Patient #14's wounds. 3. The clinical record for Patient #15, election date 01/19/2024, benefit period 01/19/2024 to 03/08/2024, included a physician Certification of Terminal Illness (CTI) that indicated Patient #15 fell 2 weeks ago (01/11/2024) that resulted in multiple fractures to the right ankle and foot while under hospice care. Patient #15 was re-admitted to hospice on 01/19/2024. The patient currently had a soft cast and was non-weight-bearing. The start of Care visit on 01/19/2024 indicated a broken right foot and ankle and cellulitis to the left lower extremities. Fall risk of 9 (10 high) soft cast in place. No interventions/instructions regarding the soft cast. The note indicated the patient had wounds and +1 edema to the lower legs. A review of the skilled Visit Notes from 01/20/2024 to 02/01/2024 failed to evidence progress toward outcomes related to edema to bilateral lower legs, redness to the coccyx (tailbone) and buttocks, and care/assessment of the soft cast to the right foot. A review of an IDG Comprehensive Assessment and Plan of Care Updated Report dated 01/31/2024 did not address interventions or instructions regarding edema to the bilateral lower legs, cellulitis to the right lower leg, soft cast placement to the right leg, redness to the coccyx and buttocks. The RN note indicated the patient was re-admitted to hospice services post-fracture. The problems, interventions, and goals to be addressed over the next two weeks include companionship and emotional support. During an IDG meeting on 01/31/2024, the IDG members did not discuss who was to care for the soft cast. There was no discussion if there was an improvement in the left lower leg that had cellulitis or areas to the buttock and coccyx.

Based on record review and interview, the agency failed to ensure the frequency and detail of the data collected were approved by the hospice's governing body specific to Gentiva 1 and failed to monitor the effectiveness and safety of services and quality of care as well as to identify opportunities for improvement regarding falls for 1 of 1 Quality Assurance Performance Improvement (QAPI) review. Findings include: --- 1. A review of the Gentiva Hospice Division QAPI plan 2023 indicated but was not limited to the Governing Body approving the QAPI plan. The plan indicated the QAPI team meets quarterly and maintains records of all QAPI activities. The plan indicated the objectives were to collect data to monitor the effectiveness and safety of services and quality of care and identify opportunities for improvement. 2. A review of the QAPI 2023 binder evidenced a Performance Improvement Project (PIP) for the following quarters: October reflecting Quarter 3 (November 1, 2023) PIP for Relias Education for delinquent staff,July reflecting Quarter 2 - (August 9, 2023) PIP in place on education, January reflecting Quarter 4 (February 1, 2023) PIP for Relias Education The agency was unable to provide a Quarter 1 report. 3. A review of the January 2024 Incident/Complaint Binder evidenced 26 falls (8 with injuries), 4. Review of the Gentiva Governing Body meeting minutes for 12/13/2023, 10/17/2023, 07/11/2023, and 03/24/2023 failed to discuss and approve the Performance Improvement Projects for Gentiva 1 of Terre Haute. 5. On 02/01/2024, the Administrator was asked about the high number of falls for January 2024. The Administrator stated the agency does not do a different intervention for each fall, and it was not uncommon to have multiple falls due to chronic restlessness. On 02/06/2024, the Administrator stated they oversee the QAPI program, and they had just been hired and had not looked at the QAPI binder or program. 6. During an interview on 02/12/2024, the Compliance Officer provided the raw data for the QAPI program from the corporate office. The Compliance Officer stated the Governing Body meetings are company-wide and not exclusive to Gentiva 1 and that the Governing Body approved the QAPI meeting minutes. The Compliance Officer could not explain why the Governing Body did not mention the Relias training PIP in the meeting minutes for the year 2023. The Governing Body meeting minutes indicated a wound PIP, but the Gentiva 1 agency did not implement a wound PIP for 2023. At that time, reviewed the detailed Incident Monthly Tracking Log (Patient) that evidenced the following: 31 falls (10 with injuries) were reported for July 2023; 24 falls (8 with injuries) were reported for August 2023; and 31 falls (9 with injuries) were reported for September 2023. The agency failed to ensure the frequency and detail of the data collected were approved by the hospice's governing body specific to Gentiva 1 and failed to monitor the effectiveness and safety of services and quality of care and to identify opportunities for improvement regarding falls.

Based on record review and interview, the agency failed to ensure the frequency and detail of the data collected were approved by the hospice's governing body specific to Gentiva 1; it also failed to maintain records of all Quality Assurance Performance Improvement (QAPI) activities for 1 of 1 QAPI review. Findings include: --- 1. A review of the Gentiva Hospice Division QAPI plan 2023 indicated but was not limited to the Governing Body approving the QAPI plan. The plan indicated the QAPI team meets quarterly and maintains records of all QAPI activities. 2. Review of the QAPI 2023 binder that was provided by the Administrator on 01/31/2024, evidence of a Performance Improvement Project (PIP) for the following quarters: October reflecting Quarter 3 (November 1, 2023) PIP for Relias (on-line) Education for delinquent staff,July reflecting Quarter 2 - (August 9, 2023) PIP in place on Relias education, January reflecting Quarter 4 (February 1, 2023) PIP for Relias Education The agency was unable to provide a Quarter 1 report. 3. Review of the Gentiva Governing Body meeting minutes for 12/13/2023, 10/17/2023, 07/11/2023, and 03/24/2023 failed to discuss and approve the frequency and detail of the data collected for Gentiva 1 Terre Haute agency. There was no mention of Relias training as a PIP. 4. During an interview on 02/06/2024, the Administrator stated they oversee the QAPI program, and they had just been hired and had not looked at the QAPI binder or program. On 02/07/2024, the Administrator provided their personnel file that evidenced they still needed to be trained on QAPI. 5. During an interview on 02/12/2024, the Compliance Officer provided the raw data for the QAPI program. The Compliance Officer stated the Governing Body meetings are company-wide and not inclusive to Gentiva 1 and that the Governing Body approved the QAPI meeting minutes. The Compliance Officer could not explain why the Governing Body did not mention the Relias training PIP. The Governing Body meeting minutes indicated a wound PIP, but the Gentiva 1 agency did not implement a wound PIP for 2023.

Based on record review and interview, the agency failed to ensure aide competencies were completed before providing patient care for 2 of 6 certified nurse aide (CNA) record reviews. (CNA 1, CNA 4) Findings include: --- 1. A policy titled "Categories/Qualifications of Personnel" was provided by the Administrator on 02/05/2024. The policy indicated that hospice aides must demonstrate their competency to a Registered Nurse by utilizing the orientation and competency checklist before independently providing patient care. 2. Review of CNA 1's personnel record, hire date 06/14/2021, failed to evidence a completed Skills Competency Checklist. 3. Review CNA 4's personnel record, hire date 08/14/2023, evidenced by a Skills Competency Checklist dated 08/16/2023 signed by CNA 4 and the former Administrator. The staff did not fill out the satisfactory performance, validation method (return demonstration/verbalization), and the date on the form. The record evidenced a Hand Hygiene and Bag Technique Competency Assessment dated 08/16/2023 signed by CNA 4 and the former Administrator. The staff did not complete the document by checking a box indicating Satisfactory or Unsatisfactory. 4. During an interview on 02/07/2024, Certified Nurse Assistant 4 stated that after completing office training and following another CNA for a week, they were on their own to care for patients. CNA 4 said the nurse did not perform a check off of their skills while in a patient's home. CNA 4 stated they don't remember if the former Administrator checked the boxes on the Skills Competency Checklist. The agency failed to ensure CNA 4 completed the Skills Competency Check before providing patient care. 5. During an interview on 02/06/2024, the current Administrator stated they were unsure why the staff did not complete the competency forms.

Based on record review and interview, the agency failed to perform a yearly in-person Certified Nurse Aide (CNA) performance evaluation with a patient during a home visit conducted by a registered nurse (RN), affecting 5 of 5 Certified Nurse Aides employed by the agency for longer than 12 months. (CNA 1, CNA 2, CNA 3, CNA 5, CNA 6). Findings include: --- 1. A 04/2021 revised document titled "Discipline Supervisory On-Site Visit" indicated CNA 2's last in-person, on-site supervisory visit was on 09/13/2022. 2. A 04/2021 revised document titled "Discipline Supervisory On-Site Visit" indicated CNA 6's last in-person, on-site supervisory visit was on 09/13/2022. 3. On 02/06/2024, a review of the personnel files of CNA 1 did not contain documentation of the last in-person, home visit, or supervisory visit conducted by an RN. 4. On 02/06/2024, a review of the personnel files of CNA 2 did not contain documentation of the last in-person, home visit, or supervisory visit conducted by an RN. 5. On 02/06/2024, a review of the personnel files of CNA 3 did not contain documentation of the last in-person, home visit, or supervisory visit conducted by an RN. 6. On 02/06/2024, a review of the personnel files of CNA 5 did not contain documentation of the last in-person, home visit, or supervisory visit conducted by an RN. 7. On 02/06/2024, a review of the personnel files of CNA 6 did not contain documentation of the last in-person, home visit, or supervisory visit conducted by an RN. 8. During an interview on 02/06/2024, the Administrator indicated they could not locate documentation of on-site, in-person CNA supervisory visits conducted in the last year for the employed CNAs. They indicated it should be done yearly for all Certified Nurse Aides and nurses.

Based on record review and interview, the agency failed to track the recruitment and retention of volunteers for 1 of 1 volunteer program review. Findings include: --- A policy titled "Volunteer Retention" was provided by the Compliance Officer on 02/07/2024. The policy indicated the agency should demonstrate ongoing efforts to recruit and retain volunteers. A monthly volunteer retention log will be maintained in the recruitment, retention, and training binder and should be updated monthly. During an interview on 02/02/2024, the Volunteer Coordinator stated they were not documenting efforts or keeping track of recruiting or retaining volunteers.

Based on record review and interview, the agency failed to meet the 5% cost savings for the year 2023 for 1 of 1 hospice agency. Findings include: --- A policy titled "Volunteer Utilization and Cost Savings" was provided by the Compliance Officer on 02/07/2024. The policy indicated cost savings should comply with the 5% volunteer utilization rate. A review of the cost-saving report indicated that 8 out of 12 months' cost savings did not meet the 5% for 2023. During an interview on 02/02/2024, the Volunteer Coordinator stated they did not meet the 5% cost savings.

Based on record review and interview, the agency failed to ensure staff completed a yearly screen for TB for 12 of 19 nurse record reviews, 5 of 6 CNA record reviews, 2 of 3 SW record reviews, and 1 of 2 Chaplain record reviews, and 1 of 1 Volunteer Coordinator record review. (RNs 1, 2, 6, 8, 12, 13, 14, 15, 17; LPN 2, 3; CNAs 1, 2, 3, 5, 6; SWs 1, 3; Chaplain 2, Volunteer Coordinator 1) Findings include: --- A policy titled "Tuberculosis [TB] Exposure Control Plan" was provided by the Administrator on 01/31/2024. The policy indicated that all employees with patient contact would be screened for TB (infectious disease) upon hire and annually. Personnel records were reviewed and failed to evidence a TB screening was completed for 2023 of the following employees: Registered Nurse (RN) 1, RN 2, RN 3, RN 6, RN 8, RN 12, RN 13, RN 14, RN 15, RN 17; Licensed Practical Nurse (LPN) 2, 3; Certified Nurse Aides (CNA) 1, CNA 2, CNA 3, CNA 5, CNA 6; Social Worker (SW) 1, SW 3, Chaplain 2, Volunteer Coordinator 1 During an interview on 02/06/2024, the Administrator could not explain why the former Administrator did not have staff complete their TB screening for 2023.

Based on record review and interview, the agency failed to ensure the orientation of skilled nursing facilities/retirement community staff furnishing care to hospice patients in the hospice philosophy, including hospice policies and procedures regarding methods of comfort, pain control, and symptom management, as well as principles about death and dying, individual responses to death, patient rights, appropriate forms, and record-keeping requirements for 15 of 15 facility files reviewed. (Entity 1 to 15) Findings include: --- 1. A policy titled "Provision of Care to Residents of SNF/NF, ICF/IID or ALF" was provided by the Administrator on 02/02/2024. The policy indicated the hospice agency was to educate skilled nursing facilities (SNF) and assisted living facilities (ALF) on the hospice philosophy, policies, and procedures regarding comfort, pain, symptom management, death and dying patient rights, and record keeping. 2. A policy titled "Coordination of Care with Contracts/Agreements" was provided by the Administrator on 02/02/2024. The policy indicated that the hospice agency was to provide education and training to inpatient and contracted facilities at least once annually. 3. A review of the Contract list provided by the office staff included 15 contracted SNF/ALF facilities. 4. During an interview on 02/02/2024, Entity 2's Assistant Director of Nursing (ADON) could not recall when the last time the agency came in to present education on hospice. The ADON stated they have multiple hospices that come into their facilities, and at some point, Entity 2's staff would be educated on hospice services. 5. During an interview on 02/05/2024, the Administrator was asked to provide documentation on where the agency oriented the skilled nursing facilities on the philosophy, policy, procedures, and pain and comfort. The Administrator stated they do not have any documentation regarding who the agency communicated with at the skilled nursing facilities regarding hospice education. The agency failed to provide and document education on hospice to SNFs and ALFs.

Based on record review and interview, the agency failed to maintain contracted employee records that included a criminal background check for 6 of 6 contract nurse record reviews. (Triage nurse 1, 2, 3, 4, 5, 6) Findings include: --- A policy titled "Selection and Hiring" was provided by the Administrator on 02/02/2024. The policy indicates a criminal background check will be obtained for positions as required by law and regulation. On 01/30/2024, the Administrator was asked to list all personnel who provide care or have access to the medical record and their background checks. A review of the personnel roster completed by Office Personnel 3 did not provide evidence of any contracted nursing staff. On 02/05/2024, the Administrator was asked to provide the contract for all contracted nurses (Telemed) and a list of employed contract nurses with access to the medical record. The Administrator provided a Gentiva Code of Conduct and a User Learning for two employees not listed on the personnel roster. On 02/12/2024 at 9:07 AM, the Administrator was asked to provide the employee records for the contracted nurses (Telemed). The Administrator provided a contract titled Carexm, LLC Master Services Agreement, which did not indicate which agency was responsible for completing criminal background checks. At that time, Governing Body 2 personnel stated there were hundreds of contracted / corporate nurses from Telemed. The surveyors gave them a list of 6 contracted nurses with access to the patient's medical records for review. Governing Body 2 personnel stated they must go through corporate to get records. The agency could not provide the contracted nurses' records by the exit date, 02/12/2024, at 1:30 PM. During an interview on 02/12/2024, the Administrator stated they would expect Telemed, not the hospice agency, to keep track of the contracted nurse's background checks and training.

Based on observations, record review, and interviews the hospice failed to develop an individualized plan of care for each patient that reflected specific patient and family goals or interventions implemented for problems identified for 11 of 13 records reviewed. (Patients 1, 2, 3, 4, 5, 8, 9, 10, and 11). Findings include: --- 1. A revised 02.2020 Policy No. 4-027 titled The Plan of Care was provided by the Administrator on 1/31/2023 at 9:15 a.m. The policy indicated, but was not limited to, "PURPOSE To ensure that an individualized plan of care is completed that complies with accepted standards of care and regulatory issues...PROCEDURE...5. The individualized plan of care will be reviewed by the interdisciplinary group...7. Each patient will be monitored for his/her response to the care of services provided against established patient goals and patient outcomes to evaluate progress toward goals..." 2. A revised 11.2020 Policy No. 4-099 titled Care/Service Coordination was provided by the Administrator on 1/31/2023 at 9:15 a.m. The policy indicated, but was not limited to, "PURPOSE To ensure the coordination of services for each patient and to minimize the potential for missed, conflicting, or duplicated services...PROCEDURE...4. Documentation of all communications will be included in the clinical record on a coordination note, IDG summary or clinical note. Documentation will include: the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication...6. Written evidence of care coordination may be found in the plan of care, clinical notes in the patients clinical record or interdisciplinary group meeting notes..." 3. The complete clinical record for patient 1, start of care (SOC) 12/13/2022, was reviewed on 2/2/2023 for the certification period 12/13/2022 to 3/12/2023. The record failed to evidence measurable and specific goals with documentation of progress toward achievement and individualized interventions implemented by each service area that clearly defined the reactions, responses, or feedback provided by the patient or family. The record failed to evidence updates, revisions, or discontinuation of goals that were unattainable, inappropriate, or became irrelevant and interventions that cant be demonstrated, comprehended, or verbalized accurately by the patient/caregiver or provides a negative outcome. 4. The complete clinical record for patient 2, SOC 1/14/2022, was reviewed on 1/31/2023, for the certification period 1/14/2022 to 4/13/2022. The record failed to evidence measurable and specific goals with documentation of progress toward achievement and individualized interventions implemented by each service area that clearly defined the reactions, responses, or feedback provided by the patient or family. The record failed to evidence updates, revisions, or discontinuation of goals that were unattainable, inappropriate, or became irrelevant and interventions that cant be demonstrated, comprehended, or verbalized accurately by the patient/caregiver or provides a negative outcome. 5. The complete clinical record for patient 3, SOC 8/16/2021, was reviewed on 2/6/2023, for the certification period 8/16/2021 to 11/13/2021 The record failed to evidence measurable and specific goals with documentation of progress toward achievement and individualized interventions implemented by each service area that clearly defined the reactions, responses, or feedback provided by the patient or family. The record failed to evidence updates, revisions or discontinuation of goals that were unattainable, inappropriate, or became irrelevant, and interventions that cant be demonstrated, comprehended, or verbalized accurately by the patient/caregiver or provides a negative outcome. 6. The complete clinical record for patient 4, SOC 1/5/2022, was reviewed on 2/6/2023, for the certification period 1/5/2022 to 4/4/2022. The record failed to evidence measurable and specific goals with documentation of progress toward achievement and individualized interventions implemented by each service area that clearly defined the reactions, responses, or feedback provided by the patient or family. The record failed to evidence updates, revisions, or discontinuation of goals that were unattainable, inappropriate, or became irrelevant, and interventions that cant be demonstrated, comprehended, or verbalized accurately by the patient/caregiver or provides a negative outcome. 7. The complete clinical record for patient 5, SOC 11/8/2021, was reviewed on 2/8/2023 for the certification period 11/8/2021 to 2/5/2022. The record failed to evidence measurable and specific goals with documentation of progress toward achievement and individualized interventions implemented by each service area that clearly defined the reactions, responses, or feedback provided by the patient or family. The record failed to evidence updates, revisions, or discontinuation of goals that were unattainable, inappropriate, or became irrelevant and interventions that cant be demonstrated, comprehended, or verbalized accurately by the patient/caregiver or provides a negative outcome. 8. The complete clinical record for patient 8, SOC 11/2/2022, was reviewed on 2/7/2023, for the certification period 11/22/2022 to 1/30/2023. The record failed to evidence measurable and specific goals with documentation of progress toward achievement and individualized interventions implemented by each service area that clearly defined the reactions, responses, or feedback provided by the patient or family. The record failed to evidence updates, revisions, or discontinuation of goals that were unattainable, inappropriate, or became irrelevant, and interventions that cant be demonstrated, comprehended, or verbalized accurately by the patient/caregiver or provides a negative outcome. 9. The complete clinical record for patient 9, SOC 1/10/2023, was reviewed on 2/8/2023, for the certification period 1/10/2023 to 4/9/2023. The record failed to evidence measurable and specific goals with documentation of progress toward achievement and individualized interventions implemented by each service area that clearly defined the reactions, responses, or feedback provided by the patient or family. The record failed to evidence updates, revisions, or discontinuation of goals that were unattainable, inappropriate, or became irrelevant, and interventions that cant be demonstrated, comprehended, or verbalized accurately by the patient/caregiver or provides a negative outcome. 10. The complete clinical record for patient 10, SOC 10/28/2022, was reviewed on 2/8/2023, for the certification period 10/28/2022 to 1/25/2023. The record failed to evidence measurable and specific goals with documentation of progress toward achievement and individualized interventions implemented by each service area that clearly defined the reactions, responses, or feedback provided by the patient or family. The record failed to evidence updates, revisions, or discontinuation of goals that were unattainable, inappropriate, or became irrelevant and interventions that cant be demonstrated, comprehended, or verbalized accurately by the patient/caregiver or provides a negative outcome. 11. The complete clinical record for patient 11, SOC 10/15/2021, was reviewed on 2/8/2023, for the certification period 10/15/2021 to 12/13/2021. The record failed to evidence measurable and specific goals with documentation of progress toward achievement and individualized interventions implemented by each service area that clearly defined the reactions, responses, or feedback provided by the patient or family. The record failed to evidence updates, revisions, or discontinuation of goals that were unattainable, inappropriate, or became irrelevant and interventions that cant be demonstrated, comprehended, or verbalized accurately by the patient/caregiver or provides a negative outcome. 12. The complete clinical record for patient 12, SOC 11/4/2022, was reviewed on 2/8/2023 for the certification period 11/4/2022 to 2/1/2023. The record failed to evidence measurable and specific goals with documentation of progress toward achievement and individualized interventions implemented by each service area that clearly defined the reactions, responses, or feedback provided by the patient or family. The record failed to evidence updates, revisions, or discontinuation of goals that were unattainable, inappropriate, or became irrelevant, and interventions that cant be demonstrated, comprehended, or verbalized accurately by the patient/caregiver or provides a negative outcome. 13. The complete clinical record for patient 13, SOC 5/19/2022, was reviewed on 2/8/2023 for the certification period 5/19/2022 to 8/16/2022. The record failed to evidence measurable and specific goals with documentation of progress toward achievement and individualized interventions implemented by each service area that clearly defined the reactions, responses, or feedback provided by the patient or family. The record failed to evidence updates, revisions, or discontinuation of goals that were unattainable, inappropriate, or became irrelevant, and interventions that cant be demonstrated, comprehended, or verbalized accurately by the patient/caregiver or provides a negative outcome. 14. During an interview on 2/2/2023 at 9:52 a.m. the Vice President of Clinical Operations indicated the electronic medical record is set up to have clinicians chart by exception and while documenting if there are issues in a particular area then other questions will prompt for answers. The clinicians have a list of specific goals and interventions that can be chosen based on the diagnoses, a particular service area assessment, and precise issues that need to be addressed. The clinicians are not required to free-write what was done during the visit or how the patient/caregiver responded, they just must select from a list of options that align directly with the intervention selected.

Based on record review, observations, and interviews, the hospice failed to maintain a system of documenting all shared communication and coordinated care provided by all disciplines for patients by non-hospice healthcare providers for 4 of 13 records reviewed. (Patients 2, 3, 9, and 11). Findings include: --- 1. A revised 11.2.2022 Policy No. 4-031 titled Interdisciplinary Group Plan of Care was provided by the Administrator on 1/31/2023 at 9:15 a.m. The policy indicated, but was not limited to, "PURPOSE To ensure the coordination of services for each patient...PROCEDURE...4. The hospice personnel will communicate changes in a timely manner via telephone, one-to-one meetings, interdisciplinary group meetings, and home visits. Documentation of all communications will be included in the clinical record on a communication note, interdisciplinary meeting form, and/or clinical note. Documentation will include the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication...11. Continuity of care will be maintained throughout the patients course with hospice. Exchange of information between hospice staff and contracted providers will be documented in the clinical record..." 2. A revised 11.2020 Policy No. 4-099 titled Care/Service Coordination was provided by the Administrator on 1/31/2023 at 9:15 a.m. The policy indicated, but was not limited to, "PURPOSE To ensure the coordination of services for each patient and to minimize the potential for missed, conflicting, or duplicated services...PROCEDURE...4. Documentation of all communications will be included in the clinical record on a coordination note, IDG summary or clinical note. Documentation will include: the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication...6. Written evidence of care coordination may be found in the plan of care, clinical notes in the patients clinical record or interdisciplinary group meeting notes..." 3. A revised 2.2022 Policy No. 4-078 titled Contents of Clinical Record was provided by the Area Director of Education on 2/3/2023 at 10:30 a.m. The policy indicated, but was not limited to, "PURPOSE To outline the requirement and components of a clinical record...PROCEDURE...1...cc. Evidence of coordination of care/service provided by the hospice with others who may be providing care/service, if applicable..." 4. The complete clinical record for patient 2, start of care (SOC) 1/14/2022, was reviewed on 1/31/2023, and included a plan of care (POC) for the certification period 1/14/2022 to 4/13/2022. The record failed to evidence clear documentation indicating an exchange of information and coordination of services between hospice staff and non-hospice healthcare providers providing care for patients and their families. During an observation in a skilled nursing facility of patient 2 on 2/1/2023 at 7:10 a.m. the hospice aide performed a bed bath and requested help from a facility staff aide for the movement of the patient during the procedure. Both aides worked seamlessly together with the hospice aide taking the lead and delegating tasks but evidenced no collaboration or interaction regarding the care of the patient and response to that care by facility staff since the hospice aide had last seen the patient. A review of the patient hospice binder at the nurses station within the facility evidenced no written or documented notes between hospice providers and facility staff providing care and the patients response when hospice staff was not in the facility. The binder failed to show coordination of care between staff or continuity of communication of care provided to patients between hospice and facility staff. During an interview on 2/1/2023 at 9:05 a.m. a facility nurse indicated not knowing for sure if the POC for patient 2 was in the binder and if the facility had its own POC. The facility nurse indicated the hospice nurse verbalizes any new orders for the patient each time a visit is made or writes the information down on a piece of paper that is then uploaded into the facility's electronic medical record before being shredded. The facility nurse was unable to point out where the POC was within the binder or where to find what was supposed to be done for the patient by each discipline. During an interview on 2/1/2023 at 9:10 a.m., Hospice Aide 3 indicated no verbal or written notes are shared with the facility hospice aide or from the facility hospice aide. Hospice Aide 3 indicated no real specific or in-depth communication occurs in any systematic way before, during, or after each visit with any facility nurse or facility hospice aide. 5. The complete clinical record for patient 3, SOC 8/16/2021, was reviewed on 2/6/2023, and included a POC for the certification period 8/16/2021 to 11/13/2021. The record failed to evidence an exchange of information and coordination of services between hospice staff and non-hospice healthcare providers providing care for patients and their families. 6. The complete clinical record for patient 9, SOC 1/10/2023, was reviewed on 2/8/2023, and included a POC for the certification period 1/10/2023 to 4/9/2023. The record failed to evidence an exchange of information and coordination of services between hospice staff and non-hospice healthcare providers providing care for patients and their families. 7. The complete clinical record for patient 11, SOC 10/15/2021, was reviewed on 2/8/2023, and included a POC for the certification period 10/15/2021 to 12/13/2021. The record failed to evidence an exchange of information and coordination of services between hospice staff and non-hospice healthcare providers providing care for patients and their families. 8. During an interview on 2/8/2023 at 10:33 a.m. The Administrator indicated all coordination of care and communication between clinicians and facility staff is documented. IDG (Inter-Disciplinary Group) meetings are scheduled for updating plans of care (POC) with all clinicians providing care including facility staff.

Upon patient record review, 3 of 13 (Patient #4, #9, #13) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #4: The nurse visit on 09/20/22 indicated patient used mylanta for his belly pain which was effective and on 10/17/22 patient used voltaren gel on his shoulder pain which was effective. These were not listed on the medication profile. [corrected on site] Patient #9: The medication profile listed lidoderm 5% patch daily topical and did not indicate location for placement of patch. [corrected on site] Patient #13: The medication profile listed oxygen 2-5L continuous however, did not contain a route.

Upon patient record review, 7 of 13 (Patients #1, 2, 4, 5, 6, 7, 9) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1: There was an order to treat UTI for patient 09/30/2022 with an antibiotic however, no evidence that plan of care was updated to reflect problems/interventions/goals. The medication orders indicated anxiety medication was discontinued 10/06/2022 however, plan of care was not updated and still contained intervention for patient/caregiver to implement anti-anxiety medication regimen. Patient had a fall noted in IDG note on 10/05/2022. No evidence that plan of care was updated to reflect problems/interventions/goals for fall precautions/safety. [corrected on site] Patient #2: The IDG note on 09/07/2022 indicated that patient had increased pain and roxanol and ativan were added to medication profile however, thee plan of care did not reflect problems/interventions/goals for pain. [corrected on site] Patient #4: The patient's orders for opioids were discontinued on 08/09/2022 however, the plan of care still contained problem/intervention/goals to educate patient/family on opioid induced constipation. [corrected on site] Patient #5: There was an order 08/10/2022 for patient to have drain placement for paracentesis at local hospital and patient/wife to be educated on process for technique however, this was not include on plan of care. [corrected on site] Patient #6: There were orders for pyridium on 08/19, and azithromycin on 09/19 and 10/01 however, the plan of care was not updated to include infection problems/interventions/goals during these dates. Patient #7: The social worker visit identified needs for the patient on 10/12/22 needing assistance with laundry and additional caregivers however, the plan of care did not include problems/interventions/goals for these needs. [corrected on site] Patient #9: The nurse visit indicated patient wounds had healed on 10/12/2022 however, wound problems/interventions/goals were still active on plan of care. The nurse comprehensive visit noted patient has pacer/defibrillator however, there was no evidence this was included on the plan of care. [corrected on site]

Upon patient record review, 3 of 13 (Patient #4, #9, #13) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #4: The nurse visit on 09/20/22 indicated patient used mylanta for his belly pain which was effective and on 10/17/22 patient used voltaren gel on his shoulder pain which was effective. There was not evidence of orders for these. [corrected on site] Patient #9: The order for lidoderm 5% patch daily topical did not indicate location for placement of patch. [corrected on site] Patient #13: The 10/22/2021 order for oxygen 2-5L continuous did not contain a route.

Upon patient record review, 4 of 13 (Patient #2, #4, #6, #12) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #2: The nurse comprehensive visit indicated patient has oxygen, wheelchair, hospital bed, and over bed table however, these were not included in the plan of care. [corrected on site] Patient #4: The nurse comprehensive visit indicated patient has oxygen however, this was not included in the plan of care. [corrected on site] Patient #6: The nurse comprehensive visit indicate patient using rollator walker however, this was not included in the plan of care. [corrected on site] Patient #12: The nurse comprehensive visit indicate patient has hospital bed however, this was not included in the plan of care.

Upon client record review, 4 of 10 applicable (Patient #6, #8, #10, #11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #6: The nurse note on 10/14/2022 indicated nursed gave vitamin B12 injection however, there was no evidence of an order for this treatment. [corrected on site] Patient #8: The order for nurse visit frequency on 09/21 was 1W1, 2W8 and 4 PRN however, the week of 09/25 there was only evidence of one visit. [corrected on site] Patient #10: The order for social work visits on 08/17/2022 was 1M1, 2M1, and 2 PRN however, there was only evidence of one visit on 09/23/2022. [corrected on site] Patient #11: The order for social work visits on 08/24/2022 was 2M2, 1M1, 2 PRN however, there was not evidence of visits in August 2022. In addition, the order for spiritual care on 08/24/2022 was 2M3, 2 PRN however, there was not evidence of visits in August 2022.

Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Upon record review, Patient #6 had falls on 09/07 and 09/21 however, these were not investigated. [corrected on site]

Upon patient client record review, 1 of 13 (Patient #12) did not have evidence that each patient record contains Advance Directives. Patient #12: Upon review the patient elected DNR and a POST signed however, was incomplete as the patient choice was not indicated.

Upon patient client record review, 1 of 13 (Patient #11) did not evidence that each patient record contains physician orders. Patient #11: There was no evidence of physician order for transfer to another hospice.

Upon client record review, 1 of 13 (Patient #13) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed.

Upon client record review, 1 of 3 applicable (Patient #2) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #2: Upon admission, the plan of care did not contain evidence that the hospice plan of care included facility coordination for problems/interventions/goals. [corrected on site]