Every finding on record at Vital Hospice Inc

1

Upon patient record review, 3 of 14 (Patient #4,5,6) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #4, No evidence of signatures of the Medical Director, MSW, SC, or RN on the initial IDG meeting form 3/18/24. The disciplines were actively involved with the patient therefore there was no evidence the IDG reviewed/revised the plan of care. Patient #5, No evidence of signature of MSW on the IDG meeting note dated 3/10/25 and 3/11/25. The disciplines were actively involved with the patient therefore there was no evidence the IDG reviewed/revised the plan of care. Patient #6, No evidence of signature of MSW on IDG meeting note dated 3/9/25 and 3/11/25. The disciplines were actively involved with the patient therefore there was no evidence the IDG reviewed/revised the plan of care.

Upon patient record review 1 of 14 (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 of supervisory visit every 14 days. Supervisory visit completed by RN on 3/21/25 and 3/5/25 which is 16 days.

Upon patient record review, 2 of 14 (Patient 5,8) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #5, 8, No evidence of Advanced Directive was completed on consent form.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) regarding the Patients Rights was met as follows: --- 1. The HA failed to ensure a completed copy of written information regarding advance directive (a legal document that outlines person's wishes in the event an individual is unable to express wishes for healthcare and treatments) policies and descriptions was provided for two of fourteen sampled patients (Patient 2 and Patient 10). (Refer to L503). 2. The HA failed to notify the patients family/responsible party regarding antibiotic medication treatment order and to ensure an access to plan of care or be involved in developing a plan of care was provided to three of fourteen sampled patients (Patient 1, Patient 2 and Patient 10). (Refer to L513). 3. The hospice agency failed to inform about the scope of services the hospice agency will provide and the limitations of the services for one of fourteen sampled patients (Patient 1). (Refer to L519). The cumulative effect of this systemic practice resulted in the failure of the hospice agency to deliver statutorily mandated compliance with Federal regulation for Patients Rights to ensure the highest quality of care are being provided to patients certified to receive the Medicare hospice benefits.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure completed copies of the written information regarding advance directive (a legal document that outlines person's wishes in the event an individual is unable to express wishes for healthcare and treatments) policies and descriptions are provided for two of fourteen sampled patients (Patient 2 and Patient 10). This failure had the potential to result in the patient, family members, and/or caregivers not knowing what the patients medical decisions are, which can result in psychological distress to the patients, family members, and/or caregivers. --- b. During a review of Patient 10s ";Personal Information", indicated a start of care (SOC) date of 11/19/2024, with a primary diagnosis of hypertensive heart disease without heart failure (is a condition where the heart is affected by high blood pressure (occurs when the force of your blood against your artery walls is too high) over time, but no heart failure). During a review of Patient 10s POC (Plan of Care, consists of different patient goals, nursing and allied health assessment and interventions to help attain those goals, and expected outcomes aligned with the patient's needs)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 1/28/2025, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus three PRN (pro re nata, which means ";as needed") visits for pain, symptom management, and to promote comfort, the Master of Social Work (MSW) to visit once a month and one PRN visit for psychosocial issues, needs and concerns, Spiritual Counselor (SC) to visit one time then on every recertification for spiritual issues and concerns and Hospice Aide (HA) to visit twice a week as needed for personal care, home making, and to promote comfort. During a home visit observation on 2/20/2025, at 10:30 a.m., at Patient 10s residence, with Registered Nurse (RN 1), Patient 10 was observed resting comfortably on his bed. Patient 10 was alert, awake and oriented to his name, time, place and events. During a concurrent review of Patient 10s hospice folder with RN1, indicated no copy of Patient 10s POLST (Physician Orders for Life-Sustaining Treatment, is a written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness). During interview with RN1 stated, she was unaware that Patient 10s POLST was not inside the hospice folder. RN 1 stated that the POLST should be with the patient at all times, and it should have been processed by the social worker. RN 1 stated that if Patient 10s heartbeat stops, CPR will be performed due to the written POLST was not with the patient or in the folder. During an interview at 10:45 a.m., with Patient 10s daughter/caregiver (Family Member 2/FM2) FM2 stated, she was the authorized representative of Patient 10 and does not remember if they have a copy of the POLST. FM2 stated she does not remember if a POLST was discussed and explained to them by the HA. During a concurrent record review and interview on 2/22/2025, at 10:45 a.m., with the Director of Patient Care Services (DPCS), indicated Patient 10s POLST was completed but was unsure why a copy was not provided and not in Patient 10s hospice folder. DPCS stated that copy of POLST should have been provided to Patient 10s and kept at hospice home folder. During a telephone interview on 2/24/2025, at 11:38 a.m., with the Master of Social Work (MSW 2), MSW2 stated that a complete POLST should have been placed in Patient 10s hospice folder for future reference and to define patients code status. MSW2 stated that a completed and readily available copy of POLST is very important for the healthcare providers future reference when Patient 10s medical condition decline or if his heartbeat stops and to avoid confusion. During a review of the HAs policy and procedure entitled, ";Do Not Resuscitate/Do Not Intubate Orders", revised November 2021, the policy and procedure indicated that a written Do Not Resuscitate (DNR) order signed by the patients physician (or authorized independent practitioner) must be on file in the patients clinical record and admission folder in the patients home and D.) A copy of the DNR/DNI order will be kept in the patient's home. a. A review of Patient 2s ";Personal Information" indicated a SOC date of 6/19/2023, with a primary diagnosis of Alzheimers disease (a disease characterized by a progressive decline in mental abilities). A review of Patient 2s Plan of Care/ Interdisciplinary Group (POC/IDG) Review for Certification period #10 dated 2/11/2025, indicated for Certified Hospice Aide (CHHA) to visit 2 times per week and Skilled Nurse (SN) to visit 1 per week with three as needed (PRN) visits. During a joint home visit on 2/19/2025 at 12:16 pm., with Registered Nurse 1 (RN1) at Patient 2s home, Patient 2 was observed awake and alert to self and location, able to answer simple questions and sitting up on her wheelchair. Patient 2 was observed with her right and left arms contracted (permanent tightening of the muscles, tendons, skin and nearby tissue that cause the joints to shorten and become stiff) in a 90-degree angle. During the visit on 2/19/2025 at 12:46 pm., with Registered Nurse 1 (RN1) Patient 2s Hospice Agency (HA) binder was reviewed. The HA binder did not contain the Physician's Orders for Life-Sustaining Treatment (POLST) written medical order from the physician that would specify the patient's preferred medical treatment to be provided during manifestation of serious illnesses. RN1 stated and confirmed Patient 2s HA binder did not have the patients original POLST form. Patient 2s caregiver provided the second HA binder for Patient 2 and stated it was the old binder. The caregiver and RN1 stated and verified there were no POLST in both binders presented. During an interview on 2/21/2025 at 12:45 pm., with the Medical Social Worker (MSW) stated, all HA patients should be provided with the original copy of their POLST in their HA binders or posted in their homes accessible and viewable in cases of any medical emergencies. The MSW also stated all POLST are to be signed by the patient or responsible party and the doctor.

Based on observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to: -Notify the patients family/responsible party regarding antibiotic medication treatment ordered to one of fourteen sampled patients (Patient 1). -Ensure patients had access and be involved in developing their plans of care for three of fourteen sampled patients (Patient 1, Patient 2 and Patient 10). These deficient practices had the potential to result in patient and/or their family member/caregiver lack of the knowledge to the care and services provided and inability to participate in the development of their plans of care. --- c. During a review of Patient 10s ";Personal Information", indicated a start of care (SOC) date of 11/19/2024, with a primary diagnosis of hypertensive heart disease without heart failure (is a condition where the heart is affected by high blood pressure (occurs when the force of your blood against your artery walls is too high) over time, but no heart failure). During a review of Patient 10s Plan of Care (POC- consists of different patient goals, nursing and allied health assessment and interventions to help attain those goals, and expected outcomes aligned with the patient's needs)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 1/28/2025, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus three PRN (pro re nata, which means ";as needed") visits for pain, symptom management, and to promote comfort, the Master of Social Work (MSW) to visit once a month and one PRN visit for psychosocial issues, needs and concerns, Spiritual Counselor (SC) to visit one time then on every recertification for spiritual issues and concerns and Hospice Aide to visit twice a week as needed for personal care, home making, and to promote comfort. During a home visit observation on 2/20/2025, at 10:30 a.m., at Patient 10s residence, with Registered Nurse (RN 1), Patient 10 was observed resting comfortably on his bed. Patient 10 was alert, awake and oriented to his name, time, place and events. During a concurrent review of Patient 10s hospice folder with RN1, the folder did not contain a copy of the Plan of Care (POC, a document that maps out needs and services supplied for a Medicare patient facing a terminal illness, as well as the patient's family/caregiver). During interview with RN 1 at 10:41 a.m., RN 1 stated that she does not know if the POC was provided to patients. RN 1 stated that it was important that patients have a copy of POC since they are part of formulating the care plan, to be actively involved and is readily available for their references during their hospice stay. During interview with FM 2 at 11 a.m., FM 2 stated that she was unsure if copy of Patient 10s POC was provided to them, stated that it would be better if they will also have a copy for their reference on what individualized care was formulated for his father (Patient 10). During interview with DPCS on 2/21/2025 at 11:51 a.m., DPCS stated that he did not know if the POC was provided to patients. DPCS stated that it was important that patients have a copy of POC since they are part of formulating the care plan, to be actively involved and is readily available for their references during their hospice stay. During a review of the HAs policy and procedure, titled ";The Plan of Care," revised November 2021, the policy and procedure indicated that the patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care. A. A review of Patient 1s ";Personal Information" document, indicated a Start of Care (SOC) date of 7/13/2024 and End Of Care (EOC) date of 7/18/2024, with a primary diagnosis of Senile degeneration of brain, not elsewhere classified (cognitive/mental decline, like memory loss, confusion, agitation, mood changes or depression, in older people). A review of Patient 1s medical record titled, Plan of Care/ Interdisciplinary Group (POC/IDG) Review for Certification period #1 indicated an order for Certified Hospice Aide (CHHA) services to visit 3 times per week starting 7/15/2024 for personal care, home making, and to promote comfort per Registered Nurse (RN) assignment, and Skilled Nurse (SN) to visit 2 per week with three as needed (PRN) (for change of condition) for pain and symptoms management and to promote comfort. During a phone interview on 2/19/2025 at 1:14 pm., with Patient 1s Family Member (FM 1), stated she was Patient 1s authorized representative and emergency contact. FM 1 stated on 7/16/2024, the HA doctor ordered an antibiotic medication, Cipro (Ciproflaxin) for Patient 1, HA did not communicate with her regarding the new medication ordered and not aware as to why the medication was prescribed and being given, until Patient 1 went to the hospital. Patient 1s family member stated the HA did not explain and did not give her the option to accept or deny the medication. During a concurrent interview and record review on 2/21/2025 at 1:01pm with Registered Nurse 2 (RN2), Patient 1s skilled visit note and assessment dated 7/17/2024 was reviewed. Patient 1s skilled visit note and assessment dated 7/17/2024 indicated there was no documentation of communicating with Patient 1s family member about the order for new antibiotic medication. RN1 stated and confirmed he completed and signed the skilled visit note and assessment dated 7/17/2024. RN1 also stated he did not receive the order from the HA doctor for Patient 1s antibiotic, and he did not communicate with Patient 1s family member on 7/17/2024 about the antibiotic as he did not get the order himself. RN1 stated he reinforced adherence to the medication order with Patient 1s caregiver and verified if the first dose had been given. During a concurrent interview and record review on 2/21/2025 at 1:30pm with the Director of Patient Care Services (DPCS), Patient 1s Electronic Medical Record (EMR) was reviewed. Patient 1s EMR indicated an order for Cipro (an antibiotic commonly used for infections) 250 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) 1 tablet by mouth twice a day for seven days for indication of Urinary tract Infection (UTI- an infection in the bladder/urinary tract) with start date of 7/16/2024. The DPCS stated and verified he spoke to the HA doctor and received the order for the medication and placed the order in patients EMR. The DPCS stated when a new medication order was received for a patient the staff should verify and communicate it with the patient and/or responsible party before initiating. The DPCS stated he did not contact Patient 1s family member about the new medication order for the antibiotic because he assumed RN2 would inform her about it on the following day when he made a home visit for Patient 1. B. A review of Patient 2s ";Personal Information" document, indicated a SOC date of 6/19/2023, with a primary diagnosis of Alzheimers disease (a disease characterized by a progressive decline in mental abilities). A review of Patient 2s medical record titled, Plan of Care/ Interdisciplinary Group (POC/IDG) Review for Certification period #10 dated 2/11/2025, indicated for Certified Hospice Aide (CHHA) to visit 2 times per week and Skilled Nurse (SN) to visit 1 per week with three as needed (PRN) visits. During a joint home visit on 2/19/2025 at 12:16 pm., with Registered Nurse 1 (RN1) at Patient 2s home, Patient 2 was observed awake and alert to self and location, able to answer simple questions and sitting up on her wheelchair. Patient 2 was observed with her right and left arms contracted (permanent tightening of the muscles, tendons, skin and nearby tissue that cause the joints to shorten and become stiff) in a 90-degree angle. During a joint home visit on 2/19/2025 at 12:42 pm., with Registered Nurse 1 (RN1) at Patient 2s home, the Hospice Agency (HA) binder was reviewed. RN1 stated and confirmed Patient 2s HA binder did not have a copy of Patient 2s most current Plan of Care/ Interdisciplinary Group (POC/IDG) Review. During an interview on 2/19/2025 at 12:46 pm., with Patient 2s Caregiver, the caregiver stated she did not remember seeing a plan of care that included the patients problems and care to be provided to the patient in the binder. During an interview on 2/24/2025 at 2:06 pm., with the Director of Patient care services (DPCS) and Director of Patient care services designee (DPCSD), the HA admission process was reviewed. The DPCSD stated she would assist the start of care admission visits during afterhours and on weekends as needed. The DPCSD stated patients are to be provided with a copy of their POC and it should be placed inside the HA binder. The DPCS and DPCSD stated they were not aware Patient 2 did not have a POC in the binder because the skilled nurses did not mention it. The DPCS stated the importance of providing patients and their family/caregiver a copy of the current IDG/POC was to promote continuity of care for all staff members involved with patients care and be aware of what is going on with the patients care. The DPCSD also stated every patient should be provided a copy of the POC upon admission.

Based on interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to inform one of fourteen sampled patients (Patient 1) about the scope of services the HA will provide and the limitations of these services. This deficient practice resulted in Patient 1's family member not being fully informed about the purpose of the hospice care services. --- A review of Patient 1s ";Personal Information" document, indicated a Start of Care (SOC) date of 7/13/2024 and End of Care (EOC) date of 7/18/2024, with a primary diagnosis of Senile degeneration of brain, not elsewhere classified (cognitive/mental decline, like memory loss, confusion, agitation, mood changes or depression, in older people). A review of Patient 1s medical record titled, Plan of Care/ Interdisciplinary Group (POC/IDG) Review for Certification period #1 indicated an order for Certified Hospice Aide (CHHA) to visit 3 times per week starting 7/15/2024 for personal care, home making, and to promote comfort per Registered Nurse (RN) assignment, and Skilled Nurse (SN) to visit 2 per week with three as needed (PRN) (for change of condition) for pain and symptoms management and to promote comfort. During a phone interview on 2/21/2025 at 3:44 pm., with Patient 1s Family Member, Patient 1s family member stated she was not informed of the extent of the hospice services for Patient 1. Patient 1s family member stated she received consent forms for Patient 1s admission for hospice via email and signed them via DocuSign. Patient 1s family member stated she was not informed about the services Patient 1 would be receiving through the HA, to include skilled nursing, aides, or wound care and how often Patient 1 would be visited and cared for by the HA. Patient 1s family member further stated she knew Patient 1 would have an initial assessment visit from HA nurse and expected agency staff to call her and inform her about the admission visit, but she did not receive a phone call. During a review of the HAs Policy and Procedure (P&P) titled, Patient Bill of Rights/Responsibilities with a revised date of November 2021, indicated, ";1. The Patient bill of rights/responsibilities statement defines the right of the patient to: F. Be informed in advance of service about the care to be furnished, the organizations scope of services and services under Medicare hospice benefit and any limitations on these services."

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) regarding the Initial and Comprehensive Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) of Patient was met as follows: --- 1. The HA failed to ensure the spiritual assessment was conducted for one of fourteen sampled patients (Patient 9). (Refer to L524). 2. The HA failed to review all the medications and update the medication profile with the currently used medications for three of fourteen sampled patients (Patient 2, Patient 5, and Patient 10). Refer to L530 3. The HA failed to conduct an initial bereavement (is the physical and mental impact of losing a loved one) assessment for two of fourteen sampled patients (Patient 1 and Patient 10). (Refer to L531). 4. The HA failed to conduct an accurate skin assessment and update the comprehensive assessment that reflected the skin abnormality in patients both groin areas for one out of fourteen sampled patients (Patient 10). (Refer to L533). The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily (written law) mandated compliance with Federal regulation for Initial and Comprehensive Assessment of the Patient to ensure the highest quality of care are being provided to patients certified to receive the Medicare hospice benefits.

Based on interview and record review the agency failed to provide an initial spiritual assessment for one of 14 sampled patients (Patient 9). This failure left Patient 9 without any spiritual guidance or comfort through the start of the hospice process. --- a. During a review of patient 9s ";admission record it indicated a start of care (SOC) date of 6/17/24 with a terminal diagnoses of end stage renal disease (gradual loss of kidney function resulting in the bodys inability to process and filter substrates out of the body)During a review of patient 9s ";plan of care/IDG review dated 12/17/24 it indicated the frequency of visits of skilled nurses (SN) is 2 per week. Spiritual counselor 1/month within 5 days of admission for initial comprehensive spiritual assessment support. During an interview conducted on 2/21/25 at 1:50 pm with the chaplain he stated that he did not complete the initial spiritual assessment for Patient 9 because she was not assigned to him. He checked his computer for her information and stated nothing was ever sent to him regarding this patient. He stated this initial assessment should be completed within 5 days of the patients admission to hospice. During an interview conducted on 2/21/25 at 2:05 pm with Director of Patient Care Services Designee (DPCS). He stated that Patient 9 was assigned to the chaplain but since he was having computer issues at the time he verbally instructed the chaplain to see her for admission which would have included the initial spiritual assessment. DPCS stated there was no confusion or misunderstanding with his instructions as chaplain had no questions regarding this matter. DPCS was able to verify that this assessment was not completed in Patient 9s documentation. When asked why is this important, DPCS stated the spiritual assessment is completed upon admission to determine what level of support the patient or family will need throughout the hospice process, he stated with no assessment completed it would have been hard to provide her with the appropriate level of support. During a review of the agencys policy entitled ";spiritual care counseling services" with a revised date of November 2021 it indicated the purpose of the policy was to provide guidelines for the appropriate assessment and provision of services to meet the spiritual needs of patients and families/caregivers. A chaplain will be assigned to each patient based on the patients needs and acceptance of these services.

Based on observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) staff failed to review all the medications and update the medication profile with the currently used medications for three of fourteen sampled patients (Patient 2, Patient 5, and Patient 10). This deficient practice had the potential to put the patients at risk for medication errors and adverse drug reactions. --- a. During a review of Patient 5s ";admission record it indicated a start of care (SOC) date of 1/17/24 with a terminal diagnoses of Cerebrovascular Disease (affects blood flow to your brain and can contribute to stroke, brain aneurysm and carotid artery disease). During a review of Patient 5s ";plan of care/IDG review dated 2/11/25 it indicated the frequency of visits of skilled nurses (SN) is 2 per week, HHA 3/ week, RN every 14 days, and MSW 1/month. During an interview conducted on 2/20/25 at 10:40 am with RN1 during the medication reconciliation he stated that the following medications are not taken by Patient 5 anymore These medications were still stored in patient 5s active medication box but not on his current MAR: 1) Famotidine 40mg 2 tabs, 2 times daily 2) Trospium 20 mg 1 tab daily 3) Miclodrine 5 mg 3 tabs every 8 hours 4) Furosemide 20mg 1 tab daily RN1 stated Patient 5 does not take these meds anymore so they should not be stored in his active medication box to avoid any unnecessary confusion. RN1 stated he was aware of this situation as he does a medication reconciliation with each visit but explained that the family has their own way of storing Patient 5s medications. RN1 stated to avoid any confusion he will speak to the family about this potentially hazardous situation. During an interview on 2/21/25 at 10:20 am., with the DPCS he stated he was aware of Patient5s family and their heavy involvement in his care. He stated the way they store Patient5s meds have no reasonable explanation and any medication that is not actively being used should be removed from his active medication box to remove any catient5s hance of potential medication errors. During a review of the agencys policy entitled ";Medication Monitoring" with a revised date of May 2022 it indicated the purpose of the policy was to define the ongoing medication monitoring process for the hospice patient. The ongoing patient medication monitoring will use a collaborative approach between the clinicians, physicians, pharmacists, patients and families/caregivers. c. During a review of Patient 10s ";Personal Information", indicated a start of care (SOC) date of 11/19/2024, with a primary diagnosis of hypertensive heart disease without heart failure (is a condition where the heart is affected by high blood pressure (occurs when the force of your blood against your artery walls is too high over time, but no heart failure). During a review of Patient 10s Current Treatment/Medication/DME (Durable Medical Equipment, medical equipment that is used repeatedly and is primarily used for medical purposes), the Current Treatment/Medication/DME List indicated that on 11/9/2024, the HAs physician ordered the following medications as part of the comfort pack for Patient 10: - Bisacodyl (a medication to treat constipation) 10 mg (milligram, a measurement unit) suppository (medications inserted into the rectum, vagina, or urethra) - Levsin (medication used to treat excessive oropharyngeal [part of the throat] secretions) 0.125 mg tablet - Lorazepam (medication used to treat anxiety and/or agitation) 2mg/ml (milliliter, a measurement unit) 0.5 ml - Ondansetron Hydrochloride (medication used to treat nausea and vomiting) 4 mg tablet - Morphine Sulfate (medication used to treat pain and dyspnea [shortness of breath or difficulty breathing]) 20 mg/ml solution - Acetaminophen (medication used to treat pain or fever) rectal suppository 650 mg During a joint home visit at Patient 10s residence with Registered Nurse 1 (RN 1) on 2/20/2025 at 10:30 a.m., observed Patient 1 awake, alert, and oriented, comfortably resting on his bed, lives in a private residence with his daughter (Family Member 2 /FM 2), who acted as the patient's caregiver. During the home visit, at 10:50 a.m., a medication review was performed with RN 1. According to FM 2, all the medications reviewed were all the medications that Patient 10 was taking. RN 1 asked FM 2 if she could look inside the refrigerator, to check the medications in the comfort pack were kept refrigerated. FM 2 looked for the comfort pack inside the refrigerator but there were no comfort pack medications found. RN 1 confirmed and stated that there was no comfort pack in Patient 10s residence. During an interview with Patient 10 at 10:58 a.m., Patient 10 stated that he did not have any pain. During an interview with RN 1 at 11 a.m., RN 1 stated usually the comfort pack was kept in the refrigerator. RN 1 stated she was not sure why the comfort pack was not available at Patient 10s home. RN 1 stated she would notify the HAs office. RN 1 stated it was important to have comfort pack available as ordered by the physician because the HA needed to ensure the medications would be available when needed. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 2/21/2025 at 10:55 a.m., the DPCS reviewed Patient 10s Current Treatment/Medication/DME List. The DPCS stated he was unsure if medications in the comfort pack was provided to Patient 10 and usually, they provide it if a patient was on continuous care or actively dying, however the DPCS stated if it was listed as active medication then it should be provided to patient and stated he was not sure why they were not available at the patients home. The DPCS stated the visiting nurse should have conducted medication reconciliation on every visit, to ensure that patient had all the ordered medications. The HA did not provide a policy and procedure on medication reconciliation as requested by the survey team on 2/24/2025. A. A review of Patient 2s ";Personal Information" document, indicated a SOC date of 6/19/2023, with a primary diagnosis of Alzheimers disease (a disease characterized by a progressive decline in mental abilities). A review of Patient 2s medical record titled, POC/IDG Review dated 2/11/2025 for Certification period #10, indicated an order for Skilled Nurse (SN) visit frequency of once per week and three as needed (PRN) visits. During a joint home visit on 2/20/2025 at 12:16 pm., with Registered Nurse 1 (RN1), at Patient 2s home, Patient 2 was observed sitting up on her wheelchair, awake, alert and oriented to self and location and able to communicate her needs. During the visit on 2/20/2025 at 12:42 pm., with RN1 at Patient 2s home, Patient 2s medication profile and medication bottles were reviewed. During review of Patient 2s HA folder, it included a medication profile list with the date of 6/29/2023. RN1 stated and confirmed that the medication profile list in patients HA folder was dated 6/29/2023, and that it was different than Patients 2s current medication profile that RN1 had with her during the home visit. RN1 stated and confirmed Patient 2s medication bottles matched and coincided with patients current medication profile that RN1 had during the home visit. RN1 stated Patient 2 was not provided with an updated medication profile. RN1 further stated she was not aware of how often the HA was to provide the patients with an updated medication profile list. During an interview on 2/21/2025 at 1:36 pm., with the Director of Patient Care Services (DPCS), the DPCS stated the HA patients are provided with a medication profile list upon admission and once a month. The DPCS stated the Skilled Nurse (SN) should do medication reconciliation at least once a month if not at every visit. The DPCS further stated the importance of the SN doing medication reconciliation during home visits and providing patients with updated medication profile list is, so patients are not stacking up on medications that they do not need, and there is no confusion for the patients or caregivers as to what medications are current and discontinued to maintain patient safety.

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to provide an initial bereavement (is the physical and mental impact of losing a loved one) assessment for two of fourteen sampled patients (Patient 1 and Patient 10). This failure had the potential to result in placing the patient/family member/caregiver at risk of spiritual and emotional distress. --- b. During a review of Patient 10s ";Personal Information", indicated a start of care (SOC) date of 11/19/2024, with a primary diagnosis of hypertensive heart disease without heart failure (is a condition where the heart is affected by high blood pressure (occurs when the force of your blood against your artery walls is too high) over time, but no heart failure). During a review of Patient 10s POC (Plan of Care, consists of different patient goals, nursing and allied health assessment and interventions to help attain those goals, and expected outcomes aligned with the patient's needs)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 1/28/2025, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus three PRN (pro re nata, which means ";as needed") visits for pain, symptom management, and to promote comfort, the Master of Social Work (MSW) to visit once a month and one PRN visit for psychosocial issues, needs and concerns, Spiritual Counselor (SC) to visit one time then on every recertification for spiritual issues and concerns and Hospice Aide (HA) to visit twice a week as needed for personal care, home making, and to promote comfort. During an interview and concurrent review of Patient 10s clinical records with the Director of Patient Care Services (DPCS), on 2/21/2025 at 1 p.m., the DPCS confirmed and stated that there was no initial bereavement assessment conducted and Patient 10s clinical record page, titled ";Bereavement Assessment," dated 11/16/2024 was incomplete and has no clinicians signature. The DPCS stated there were no other documented evidence that an Initial Bereavement Assessment was conducted for Patient 10. The DPCS stated a bereavement assessment needed to be conducted within five days of admission. The DPCS stated Patient 10 did not have an initial bereavement assessment conducted based on the clinical records and the Spiritual Chaplain (SC) or the Medical Social Worker (MSW) should have been completed it. DPCS stated that it is important to conduct an initial bereavement assessment to the patient and family members to anticipate what services, potential problems or risks that need to address. During a telephone interview on 2/24/2025, at 11:38 a.m., with the Master of Social Work (MSW 2), MSW2 stated that initial bereavement assessment should be done by the SC during admission to determine any potential risks or problems when the time comes that patient passed away and patients family will be in bereavement process. MSW2 stated that he is unsure why the initial bereavement assessment of Patient 10 was not completed. During a review of the HAs policy and procedure, titled ";Bereavement Services," revised November 2021, the policy and procedure indicated that the hospice agency will provide bereavement services to the families/caregivers of hospice patients both before and after the patients death in accordance with the plan of care, a bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice and information gathered will be incorporated into the plan of care and considered in the bereavement plan of care. A. A review of Patient 1s ";Personal Information" document, indicated a Start of Care (SOC) date of 7/13/2024 and End of Care (EOC) date of 7/18/2024, with a primary diagnosis of senile degeneration of brain, not elsewhere classified (cognitive/mental decline, like memory loss, confusion, agitation, mood changes or depression, in older people). A review of Patient 1s medical record titled, Plan of Care/ Interdisciplinary Group (POC/IDG) Review for Certification period #1 with start date of 7/15/2024, indicated an order for Bereavement Counselor to visit within 5 days of admission for initial comprehensive bereavement assessment with one as needed (PRN) for care and support. During a concurrent interview and record review on 2/21/2025 at 1 p.m. with the Director of Patient Care Services (DPCS), Patient 1s Electronic Medical Record (EMR) was reviewed. The DPCS stated and confirmed that there was no documented evidence of the initial bereavement assessment was completed. The DPCS stated the bereavement assessment needed to be conducted within five days of the patients admission and completed by the Hospice Agencys (HA) Spiritual Chaplain (SC) or the Medical Social Worker (MSW). DPCS stated that it was important to conduct an initial bereavement assessment to the patient and family members to anticipate what services, potential problems or risks that need to be addressed.

The Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to conduct an accurate skin assessment and update the comprehensive assessment that reflected the skin abnormality in patients both groin areas for one out of fourteen sampled patients (Patient 10). This deficient practice had the potential to result an inaccurate assessment to appropriately address patients needs. --- During a review of Patient 10s ";Personal Information", indicated a start of care (SOC) date of 11/19/2024, with a primary diagnosis of hypertensive heart disease without heart failure (is a condition where the heart is affected by high blood pressure (occurs when the force of your blood against your artery walls is too high) over time, but no heart failure). During a review of Patient 10s POC (Plan of Care, consists of different patient goals, nursing and allied health assessment and interventions to help attain those goals, and expected outcomes aligned with the patient's needs)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 1/28/2025, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus three PRN (pro re nata, which means ";as needed") visits for pain, symptom management, and to promote comfort, the Master of Social Work (MSW) to visit once a month and one PRN visit for psychosocial issues, needs and concerns, Spiritual Counselor (SC) to visit one time then on every recertification for spiritual issues and concerns and Hospice Aide (HA) to visit twice a week as needed for personal care, home making, and to promote comfort. During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 2/24/2025 at 12:20 p.m., the clinical records of Patient 10 indicated the following: -Patient 10s clinical record titled ";Visit Note RN (Registered Nurse)," dated 1/11/2025, indicated on the ";Integumentary-Skin" section, documented as – none to rash (An area of the skin that has changes in texture or color and may look inflamed or irritated), none to wounds (an injury to the body that can involve a cut, tear, or break in the skin or tissue), none to ulcers/bed sores ( a sore or damaged area on the skin that develops when pressure is applied to the same spot for a long time), none to other symptom, comments were left blank, and the ";Narrative" section indicated a documentation ";noted with redness on his (Patient 10) groin area." -Patient 10s clinical record titled ";Visit Note RN (Registered Nurse)," dated 1/23/2025, indicated on the ";Integumentary-Skin" section, documented as – none to rash, none to wounds, none to ulcers/bed sores, none to other symptom, comments were left blank, and the ";Narrative" section indicated a documentation ";patient was noted to be cooperative upon visit and redness on the groin is noted with improvement." - Patient 10s clinical record titled ";Visit Note LVN (Licensed Vocational Nurse)," dated 1/27/2025, indicated on the ";Integumentary-Skin" section, documented as – none to rash, none to wounds, none to ulcers/bed sores, none to other symptom, comments were left blank, and the ";Narrative" section indicated a documentation ";Redness on the groin areas are resolving." DPCS confirmed and stated that based on the clinical records reviewed, the skin assessments by the visiting nurses for Patient 10 were inaccurate and inconsistent. DPCS stated that both the Integumentary-Skin section and narrative documentations of nurses for patients should be consistent and reflect the status of the patient to avoid confusion among the healthcare team or possible delay in providing care for patients. During a review of the agencys policy and procedure titled ";Comprehensive Assessment", dated November 2021, the procedure indicated that during the comprehensive patient assessment, all baseline data and other relevant information will be documented: G. A physical assessment, including blood pressure, temperature, pulse, respiration, skin, and other relevant data related to physical findings and the patients terminal illness.

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs) for Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), Care Planning, and Coordination of Services was met as follows: --- 1. The HA failed to provide care and services regarding missed hospice aide/nurse visits according to the plan of care for four of fourteen sampled patients (Patient 1, Patient 2, Patient 7 and Patient 8). (Refer to L543). 2. The HA failed to ensure that education and training were provided to patient/patients caregiver related to blood pressure/blood sugar monitoring logs, bleeding precautions while on Clopidogrel (an anti-coagulant medication that is used to prevent and treat blood clots in blood vessels and the heart), proper disposal of used lancets, skin and foley catheter ( a device that drains urine from the urinary bladder (muscular hollow organ that holds the urine) into a collection bag outside of the body) care for two of fourteen sampled patients (Patient 1 and Patient 10). (Refer to L544). 3. The HA failed to develop an individualized plan of care (POC, a document that maps out needs and services supplied for a Medicare patient facing a terminal illness, as well as the patient's family/caregiver) to address integumentary (skin) status and management/interventions for bleeding precautions while on anti-coagulant medication for three of fourteen sampled patients (Patient 1, Patient 2 and Patient 10). (Refer to L545). 4. The HA failed to provide an initial skin treatment necessary to meet patients needs for one of fourteen sampled patients (Patient 1). (Refer to L549). 5. The HA failed to provide a necessary medical supply (suction machine, medical device that is primarily used for removing obstructions, such as mucus, saliva, blood, or secretions from a person's airway) as ordered by the physician for one of fourteen sampled patients (Patient 10). (Refer to L550). 6. The HA failed to ensure a blood sugar, and a blood pressure log were maintained according to the plan of care to monitor and/or assess effectiveness of current and new medication/treatment to one of fourteen sampled patients (Patient 10). (Refer to L555). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure provision of the highest quality care and services to all certified hospice patients.

Based on interview and record review the Hospice Agency (HA) failed to follow all orders in the individualized Plan of Care (POC [documents the process of identifying a patient's needs and facilitating complete care and ensures collaboration among nurses, patients, and other healthcare providers]) for three of fourteen samples patients (Patient 1, Patient 2, and Patient 7). This failure left Patient 1, Patient 2 and Patient 7 with missed home visits that had the potential to result in patients not receiving the needed services and treatments as ordered by the physician that could affect the patients' health status and well-being. --- c. During a review of Patient 7s ";admission record it indicated a start of care (SOC) date of 12/11/24 with a terminal diagnoses of Chronic Obstructive Pulmonary Disease (COPD is a condition involving constriction of the airways and difficulty or discomfort in breathing) During a review of Patient 7s ";plan of care/IDG review dated 1/14/25 it indicated the frequency of visits of skilled nurses (SN) is 1 per week. Declined HHA and SC. During a review of Patient 7s home visits it indicated no home visits were made between the following dates, no evidence attempts to reschedule home visits for the week, no documentation of the missed visit, no evidence the MD was notified of the missed visits to the following: 1) 12/18/24 – 12/18/24 (10 days) 2) 1/23/25 -- 2/13/25 (21 days) During an interview conducted on 2/21/25 at 10:20 am., with the DPCS he stated visits were missed for Patient 7 on the dates above. DPCS stated these missed visits should have been rescheduled for the same week so the patient would not have missed her ordered visit. DPCS further stated MD should have been informed of missed visit and should have been documented on a communication note for all to see. During a review of the agencys policy entitled ";Missed Visits" with a revised date of November 2021 it indicated the purpose of the policy was to ensure that missed visits are documented and does not affect the quality of patient care. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record. If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so the physician ordered frequency is maintained and would not be considered a missed visit. A. A review of Patient 1s ";Personal Information" document, indicated a Start of Care (SOC) date of 7/13/2024 and End of Care (EOC) date of 7/18/2024, with a primary diagnosis of Senile degeneration of brain, not elsewhere classified (cognitive/mental decline, like memory loss, confusion, agitation, mood changes or depression, in older people). A review of Patient 1s medical record titled, Plan of Care/ Interdisciplinary Group (POC/IDG) Review for Certification period #1 indicated an order with start date of 7/13/2024, for Certified Hospice Aide (CHHA) to visit 3 times per week starting 7/15/2024 for personal care, home making, and to promote comfort per Registered Nurse (RN) assignment. During a review of Patient 1s EMR indicated the CHHA did not submit a weekly nursing note for week of 7//15/2024 to 7/18/2024. During a concurrent interview and record review on 2/21/2025 at 12:12p m with the DPCS, Patient 1s EMR was reviewed. Patient 1s EMR indicated there was no CHHA visit note submitted under ";History of HA visits" section. The DPCS stated and confirmed Patient 1 had an order for CHHA visits 3 times per week to start on 7/15/2024. The DPCS stated and confirmed there was no documented evidence of CHHA visited Patient 1 the week of 7/15/2024 to 7/18/2024, and no documented missed visit note or communication note. The DCPS stated the HA had been focusing on communicating with Patient 1s Family Member and listening to her concerns, they wanted to find a CHHA to meet Patient 1s Family Member needs. The DPCS stated and conformed Patient 1s POC was not being followed as CHHA was not scheduled and visited Patient 1 by 7/15/2024 as POC indicated. The DPCS further stated the importance of following through with physician order to provide patient with CHHA as ordered, because Patient 1 had skin issues and lack of mobility. B. A review of Patient 2s ";Personal Information" document, indicated a SOC date of 6/19/2023, with a primary diagnosis of Alzheimers disease (a disease characterized by a progressive decline in mental abilities). A review of Patient 2s medical record titled, Plan of Care/ Interdisciplinary Group (POC/IDG) Review for dated 12/31/2024 for Certification period #9, indicated an order for Skilled Nurse (SN) visit one time a week and three PRN visits. During a review of Patient 2s EMR indicated the SN did not submit a weekly nursing note for week of 12/29/2024–1/4/2025. During a concurrent interview and record review on 2/21/2024 at 1:45 pm., with the DPCS, Patient 2s EMR was reviewed. Patient 2s EMR indicated there was no documented SN name on Patient 2s visits calendar for the week of 12/29/2024 to 1/4/2025. The DPCS stated and confirmed when there is no SN name on the patients visits calendar it means there was no SN visit completed for that week The DPCS stated and confirmed there was no documented visit for patient 2, for the week of 12/29/24 to 1/4/25 from the SN and there was no missed visit documentation in the communication log section. The DPCS further stated and confirmed Patient 2s Plan of Care (POC) was not being followed since the SN did not visit, once per week, as indicated on the POC.

Based on observation, interview, and record review, The Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to: 1. Ensure that education and training were provided to patient/patients caregiver related to blood pressure/blood sugar monitoring logs, bleeding precautions while on Clopidogrel (an anti-coagulant medication that is used to prevent and treat blood clots in blood vessels and the heart), proper disposal of used lancets to one of fourteen sampled patients (Patient 10). 2. Ensure that education and training were provided to patient/patients caregiver related to skin and foley catheter ( a device that drains urine from the urinary bladder (muscular hollow organ that holds the urine) into a collection bag outside of the body) care for one of fourteen sampled patients (Patient 1). These failures resulted in the hospices inability to provide patients/patient caregivers understanding and training of possible risks, side effects, and proper management of the patient's health status and wellbeing. --- b. During a review of Patient 10s ";Personal Information", indicated a start of care (SOC) date of 11/19/2024, with a primary diagnosis of hypertensive heart disease without heart failure (is a condition where the heart is affected by high blood pressure (occurs when the force of your blood against your artery walls is too high) over time, but no heart failure). During a review of Patient 10s POC (Plan of Care, consists of different patient goals, nursing and allied health assessment and interventions to help attain those goals, and expected outcomes aligned with the patient's needs)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 1/28/2025, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus three PRN (pro re nata, which means ";as needed") visits for pain, symptom management, and to promote comfort, the Master of Social Work (MSW) to visit once a month and one PRN visit for psychosocial issues, needs and concerns, Spiritual Counselor (SC) to visit one time then on every recertification for spiritual issues and concerns and Hospice Aide (HA) to visit twice a week as needed for personal care, home making, and to promote comfort. During a review of Patient 10s clinical record ";Current Treatment/Medication/DME (Durable Medical Equipment; any medical equipment used in the home to aid in a better quality of living)" indicated listed medication which includes: -Order date of 11/8/2024, Insulin Glargine (A long acting insulin drug used to control the amount of sugar in the blood of patients with diabetes, a chronic disease where the body does not produce or use insulin properly, Insulin is a hormone that helps glucose (sugar) from food get into the cells for energy, without enough insulin or proper insulin use, glucose builds up in the bloodstream, leading to high blood sugar levels), dosage: 20 units, route: subcutaneous (the layer of tissue that underlies the skin), frequency: at bedtime-routinely, hold if blood sugar below 100mg (milligram, unit of measurement)/dl (deciliter, unit of measurement), indication: Diabetes -Order date of 2/17/2025, Amlodipine Besylate ( to treat high blood pressure or hypertension, a condition in which the pressure of the blood in the arteries is too high), strength: 5mg, dosage: 1 tablet, route: by mouth, frequency: once daily-routinely, hold for SBP (systolic blood pressure, the pressure in the arteries when the heart contracts and pumps blood) below 110 and HR (heart rate) below 60 BPM (beat per minute). -Order date of 11/8/2024, Lisinopril (to treat high blood pressure or hypertension, a condition in which the pressure of the blood in the arteries is too high), strength: 10 mg, dosage: 1 tablet, route: by mouth, frequency: two times a day, hold for SBP (systolic blood pressure, the pressure in the arteries when the heart contracts and pumps blood) below 100 and HR (heart rate) below 60 BPM (beat per minute) -Clopidogrel 75 milligrams (mg, unit of weight) tablet, one tablet, oral (by mouth), daily for CVA (Cerebrovascular Accidents, are caused by blood clots and broken blood vessels in the brain) prophylaxis (to prevent disease or preserve health)/blood thinner. During a concurrent observation and interview on 1/20/2025, at 10:30 a.m., with Registered Nurse (RN1), in Patient 10s residence for a joint home visit, Patient 10 was comfortably lying on his bed with his walker by his side. Patient 10s Primary Caregiver and daughter (Family Member 2/FM2) confirmed that Patient 10 is still taking Clopidogrel medication to prevent further incidents of strokes or blood clots. During interview at 10:45 a.m., FM2 stated that she was unsure of what to look for while her father (Patient 10) is on Clopidogrel. FM2 stated that she was unsure if the visiting nurses provided teachings to them of what to look for while her father is on anti-coagulant medication. During review of Patient 10s hospice agencys home folder, there was no indication of any written instructions for Patient 10 or his FM2 related to anti-coagulant therapy use. During interview at 10:45 a.m. with RN1, RN1 stated that she provided some teachings to Patient 10 and his FM2 of what to look for while on anti-coagulant medication like bleeding, unusual bruising and black stools. RN 1 stated that the HA did not provide written instructions to Patient 10 and and FM2 for their reference when they needed to review it. During the home visit, at 10:50 a.m., a medication review was performed with RN 1, which include the current medications of Glargine insulin (long-acting medication to help lower high blood sugar) and amlodipine (medication to treat high blood pressure). According to FM 2, all the medications that reviewed were all the medications that Patient 10 was taking. FM2 stated that she followed the instructions in administering the insulin. FM2 stated that she checks her fathers (Patient 10) blood sugar using the glucometer, and if it is under 100 mg/dl reading, stated she does not give the insulin to his father and will inform the HA. FM2 stated that her fathers blood sugar is always above 100mg/dl and there were no instances that her fathers blood sugar was below 100mg/dl. FM2 stated that she does not write down the blood sugar readings of her father and she is unsure and if the HA provided a log to write down her fathers blood sugar readings. FM2 stated that she also gives her fathers medications including the medication for blood pressure (amlodipine). FM2 stated that she checked her fathers blood pressure (BP) before giving the medication and if the above number (SBP) is below110 for amlodipine, SBP below 100 for lisinopril, and the heart rate is below 60, she will not give the medication. FM 2 stated that her fathers BP readings and heart rate readings were always above the given parameters, and she does not write down her fathers BP readings for record. FM2 stated that she is unsure if there were log sheets provided by the HA nurse to write down the BP and blood sugar readings of her father. FM2 stated that she does not remember if she was taught by the HA nurses to write down the blood sugar and blood pressure readings of her father. During an interview with RN 1 at 11 a.m., RN 1 stated she provided teachings to FM2 regarding the parameters and to write down the blood pressure and blood sugar readings of Patient 10, but unsure if she documented that teachings were provided to Patient 10 and/or FM2. RN 1 stated that FM2 supposed to log in the readings of Patient 10s daily blood sugar and blood pressure. RN 1 stated that she was unsure if HA provides BP/blood sugar readings log sheets to patients and/or caregivers. RN 1 stated that it is important that patient and/or caregiver writes down the daily BP/blood sugar readings to be able to monitor effectively if current medications are working and if there any changes and improvement. During an interview with FM2 at 11:02 a.m., FM2 stated that she checks the blood sugar of her father before administering the insulin and follows the parameters as written in the medication list. FM2 stated that she wastes the used lancets (a small, sharp needle used to prick the skin to obtain a blood sample for testing blood sugar levels) to used bottled water, then dispose it to their container bin. FM2 stated that she was unsure if HA or visiting nurses taught her on how to properly dispose the used lancets. RN 1 stated that she provided some teachings to Patient 10 and FM2 on how to properly dispose used lancets but did not document it. RN 1 stated that she is unsure if HA provide the appropriate waste container to dispose the lancets for Patient 10 and/or FM2. RN 1stated that used lancets should be disposed appropriately to follow the infection control and prevent the spread of disease. During an interview with the Director of Patient Care Services (DPCS) on 2/21/2025, at 12:50 p.m., the DPCS reviewed Patient 10s Current Treatment/Medication/DME List, POC/IDG Review dated 1/28/2025, Visit Note RN and LVN (Licensed Vocational Nurse) dated 1/11/2025, 1/13/2025, 1/23/2025 and 1/27/2025 with no visiting nurses' documentations related to teachings for anti-coagulation medications, BP/blood sugar logs and proper disposal of used lancets. DPCS stated that it is important for the clinical staffs to provide verbal teachings and written instructions to patients if they are taking some medications that could potentially have side effects, like anti-coagulants. DPCS stated that written instructions provided to patients and their caregivers will help them of symptoms to look for and when to seek immediate care. DPCS stated that HA should provide an approved container to dispose used lancets and visiting nurses have to ensure that it was provided to patient and/or caregivers, DPCS stated following infection control is very important to prevent spread of disease. The DPCS stated the HA did not maintain a blood sugar log and blood pressure log for Patient 10, stated but FM2 should maintain one and the HA visiting nurse should reminded and educate them. The DPCS stated he was not aware that there was no blood sugar log and blood pressure log maintained for Patient 10. The DPCS stated that verbal report by FM2 to HA visiting nurses was not an adequate monitoring. The DPCS stated there could be negative outcome of not properly monitoring Patient 10s blood sugar and blood pressure, such as the blood sugar or blood pressure could be too low or too high, and the HA visiting nurses, and the physician would not be aware. The DPCS stated that RN 1 should have documented the blood sugar reading and blood pressure reading maintenance records teachings and provided to Patient 10 and/or FM2. Per DPCS, the HA staff should have instructed to maintain a blood sugar and blood pressure logs as part of the overall disease management for Patient 10. During a review of the HAs policy and procedure, titled ";Patient Education Process," revised November 2021, the policy and procedure indicated that purpose is to provide guidelines for giving specific instruction and information to patients and family/caregivers regarding hospice services, patients and family/caregivers will receive education in verbal, visual and written format, as appropriate, the scope of teaching will be determined by the assessed needs, abilities, learning preferences, and readiness to learn of the patient and family/caregiver, as well as the plan of care, documentation of patient and family/caregiver education consist of A. Describing what was taught to the patient, B. Describing the patients response to the teaching, including the level of understanding and the ability to repeat or demonstrate what was taught, D. Describing teaching planned for subsequent visits, Patient and family/caregiver education will be interdisciplinary and interactive as appropriate to the plan of care, at interdisciplinary group meetings, patient education and learning needs/processes will be discussed by all clinicians involved with the care. During a review of the HAs policy and procedure, titled ";Identification, Handling, and Disposal of Hazardous Waste," revised November 2021, the policy and procedure indicated a purpose to provide guidelines for the instruction of patients and family/caregivers in the identification, handling, and disposal of hazardous materials and wastes, the patient and family caregiver will receive, when appropriate, information and instruction regarding the identification, handling, and disposal of hazardous materials and wastes, as part of the comprehensive assessment, the patient will be assessed for educational needs related to identification, handling, and disposal of hazardous materials and wastes, documentation of patient and family/caregiver instruction in the clinical which include: A. Information taught, C. Patient and family/caregiver understanding, E. Response to teaching. A. A review of Patient 1s ";Personal Information" document, indicated a Start of Care (SOC) date of 7/13/2024 and End of Care (EOC) date of 7/18/2024, with a primary diagnosis of Senile degeneration of brain, not elsewhere classified (cognitive/mental decline, like memory loss, confusion, agitation, mood changes or depression, in older people). During a concurrent interview and record review on 2/24/2025 at 11:56 am with the Director of Patient Care (DPCS), Patient 1s Electronic Medical Record (EMR) was reviewed. Patient 1s EMR indicated the Plan of Care/ Interdisciplinary Group (POC/IDG) did not indicate care plan for the patients skin wounds that included treatment, responsible person for applying treatment and education or training that was provided. The DPCS stated and confirmed Patient 1s initial POC/IDG did not have documented evidence of a care plan for the management of Patient 1s skin wounds and if any education or training was to be provided to the caregiver. The DPCS stated during IDG meetings the care plans are entered manually by the team during conversation of the patient. The DPCS further stated if a care plan for a patients condition was not documented then it did not happen and can indicate the IDG did not communicate about it. The DPCS also said the importance of providing education of skin care and treatment to a patient or caregiver and document it, is to promote communication and cohesiveness within the patients care team. During a concurrent interview and record review on 2/21/2025 at 1:01pm with Registered Nurse 2 (RN2), Patient 1s skilled visit note and assessment for the date of 2/17/2025 was reviewed. Patient1s skilled visit notes and assessment indicated RN2 inserted a foley catheter (a thin flexible tube inserted into the bladder to drain the urine) for the patient and there was no documented evidence of education or training provided to the caregiver. RN2 stated and confirmed he completed and signed the skilled visit note and assessment dated 2/17/2025. RN2 stated and confirmed the skilled visit note and assessment did not have documented evidence that education and training of foley catheter management was provided to the patients caregiver. During a concurrent interview and record review on 2/24/2025 at 12 pm with the DPCS, Patient 1s skilled visit notes and assessment for the date of 2/17/2025 was reviewed. The DPCS stated and confirmed there was no documented evidence of foley catheter care and management provided to the patients caregiver. The DPCS further stated the importance of providing education to patients and caregivers for foley catheter care and management is for continuity of care, to make sure everyone is aware of how to care for the patient and who is responsibility is to do what in the care. The DPCS stated it is important to document what was done, if not documented not done.

Based on observation, interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to develop an individualized and patient-centered Plan of Care (POC, a document that maps out needs and services supplied for a Medicare patient facing a terminal illness, as well as the patient's family/caregiver) that includes management of potential problems, interventions, goals and status of integumentary ( the body's outer covering, consisting of the skin, hair, nails, and glands and acts as a protective barrier, regulating body temperature, sensing stimuli) and use of Clopidogrel (an anticoagulant [blood thinner] medication that can cause serious bleeding) for three of fourteen sampled patients (Patient 1, Patient 2 and Patient 10). This deficient practice resulted in patients did not have a POC for the current health status for management of symptoms of terminal illness that could cause delayed care, and undetected signs of physical, emotional, and spiritual needs when transitioning to the final stages of dying process. --- c. During a review of Patient 10s ";Personal Information", indicated a start of care (SOC) date of 11/19/2024, with a primary diagnosis of hypertensive heart disease without heart failure (is a condition where the heart is affected by high blood pressure (occurs when the force of your blood against your artery walls is too high) over time, but no heart failure). During a review of Patient 10s ";Re-Cert Assessment," dated 2/06/2025, the Re-Cert Assessment indicated in the ";Integumentary (Skin or bodys outer layer)-Skin" section was documented ";Friction and Shear – Potential problem" and ";Other Observations (if applicable) – Patient skin was intact. No breakdown was noted. Provided teaching to daughter on prevention of having skin breakdown due to incontinence or lessen mobility and verbalized understanding." During a review of Patient 10s clinical record ";Current Treatment/Medication/DME (Durable Medical Equipment; any medical equipment used in the home to aid in a better quality of living)" indicated listed medication which includes: - Clopidogrel 75 milligrams (mg, unit of weight) tablet, one tablet, oral (by mouth), daily for CVA (Cerebrovascular Accidents, are caused by blood clots and broken blood vessels in the brain) prophylaxis (to prevent disease or preserve health)/blood thinner. During a review of Patient 10s POC (Plan of Care, consists of different patient goals, nursing and allied health assessment and interventions to help attain those goals, and expected outcomes aligned with the patient's needs)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 1/28/2025, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus three PRN (pro re nata, which means ";as needed") visits for pain, symptom management, and to promote comfort, the Master of Social Work (MSW) to visit once a month and one PRN visit for psychosocial issues, needs and concerns, Spiritual Counselor (SC) to visit one time then on every recertification for spiritual issues and concerns and Hospice Aide (HA) to visit twice a week as needed for personal care, home making, and to promote comfort. Upon further review, Patient 10s POC/IDG did not include a care plan for Integumentary status and bleeding precautions while on anti-coagulant medication. During a concurrent observation and interview on 1/20/2025, at 10:30 a.m., with Registered Nurse (RN1), in Patient 10s residence for a joint home visit, Patient 10 was comfortably lying on his bed with his walker by his side. Patient 10s Primary Caregiver and daughter (Family Member 2/FM2) stated that her father (Patient 10) is bed bound (confine on bed) and wheelchair bound (confine on wheel chair), FM2 stated it is difficult for her father to walk. FM 2 stated she takes good care of her fathers skin so that he will not develop any wounds or skin problems. FM2 stated her father can reposition himself while on bed or on wheelchair and she also constantly reminded him. FM2 stated that she is unsure if visiting nurses taught her regarding proper skin care for her father. FM 2 confirmed and stated that that Patient 10 is still taking Clopidogrel medication to prevent further incidents of strokes or blood clots. During interview at 10:45 a.m., FM2 stated that she was unsure of what to look for while her father (Patient 10) is on Clopidogrel. FM2 stated that she was unsure if the visiting nurses provided teachings to them of what to look for while her father is on anti-coagulant medication. During review of Patient 10s hospice agencys home folder, there was no indication of any written instructions for Patient 10 or his FM2 related to anti-coagulant therapy use or regarding proper skin care and repositioning to avoid any wounds. During interview at 10:45 a.m. with RN1, RN1 stated that she provided some teachings to Patient 10 and his FM2 of what to look for while on anti-coagulant medication like bleeding, unusual bruising and black stools and patients repositioning to prevent skin breakdown. RN 1 stated that the HA did not provide written instructions to Patient 10 and FM2 for their reference when they needed to review it. During an interview and concurrent record review of Patient 10s following clinical records on 2/21/2025, at 3:30 p.m., with the Director of Patient Care Services (DPCS), The DPCS confirmed and stated that Patient 10s clinical record titled ";The Plan of Care (POC)/Interdisciplinary Group (IDG, team consists of the Medical Director, PCA, Social Worker, Spiritual Chaplain and Volunteer Coordinator that work together towards the goal of the patient) Review," dated 12/17/2024, 12/31/2024, 1/14/2025, and 1/28/2025 the POC/IDG Review indicated no management of potential problems, interventions, goals and status of integumentary and bleeding precautions while on Clopidogrel anti-coagulant medication. DPCS stated that a care plan should have been formulated for Patient 10 since he is bedbound and wheelchair bound and has a high risk of developing skin breakdown, DPCS stated that care plan has to address potential problems and for the nursing team to be aware of the goals and interventions and current health status of patient. During a review of the HAs policy and procedure, titled ";The Plan of Care," revised November 2021, the policy and procedure indicated that a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. A. A review of Patient 1s ";Personal Information" document, indicated a Start of Care (SOC) date of 7/13/2024 and End of Care (EOC) date of 7/18/2024, with a primary diagnosis of Senile degeneration of brain, not elsewhere classified (cognitive/mental decline, like memory loss, confusion, agitation, mood changes or depression, in older people). During a review of Patient 1s medical record titled Comprehensive Nursing Assessment dated 7/13/2024 it was noted to be signed by the DPCSD. Patient 1s Comprehensive Nursing Assessment, under skin impairment assessment indicated Patient 1 to have redness to abdomen area and rectal area. During an interview on 2/21/2025 at 11:26 am., with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated her role at the Hospice Agency (HA) includes doing after hour and weekend admissions as needed and participate in Interdisciplinary Group (IDG) meetings every two weeks. During a concurrent interview and record review on 2/21/2024 at 11:51 am., with the DPCSD, Patient 1s Initial Plan of Care/ Interdisciplinary Group (POC/IDG) Review for Certification period #1 dated 7/15/2024 was reviewed. The DPCSD stated and confirmed Patient 1s Initial POC/IDG did not have documented evidence of any care plans for the patients care and that was including no care plans for the patients skin redness treatment, management and education to the caregiver. During a concurrent interview and record review on 2/24/2024 at 11:50 am., with the Director of Patient Care Services (DPCS), Patient 1s POC/IDG dated 7/15/2024 and 7/16/2024 was reviewed. The DPCS stated and confirmed Patient 1s POC/IDG dated 7/15/2024 and 7/16/2024 did not have documented evidence of care plans for the management and treatment of Patient 1s skin and if any education or training was provided to the caregiver. The DPCS stated during IDG meetings, the care plans were entered manually by the team during conversation of the patient. The DPCS further stated if a care plan for a patients condition was not documented then it did not happen and can indicate the IDG did not communicate about it. The DPCS stated the importance of developing POC with IDG was to promote communication and cohesiveness of care within the patients care team. B. A review of Patient 2s ";Personal Information" document, indicated a SOC date of 6/19/2023, with a primary diagnosis of Alzheimers disease (a disease characterized by a progressive decline in mental abilities), and list of secondary diagnosis to include essential primary hypertension (high blood pressure with no identifiable cause). During a concurrent interview and record review on 2/21/2024 at 12:49 pm with the DPCS, Patient 2s medical record titled Current treatment/ Medication/Durable medical equipment (DME) List was reviewed. The DPCS stated and confirmed Patient 2s current medication list included an active medication of Losartan Potassium (drug used to treat high blood pressure) 25 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) 1 tablet daily by mouth for hypertension (high blood pressure). During a concurrent interview and record review on 2/21/2024 at 12:49 pm with the DPCS, Patient 2s POC/IDG Review for certification period #10 dated 2/11/2025 was reviewed. The DCPS stated and confirmed Patient 2s POC/IDG Review for certification period #10 dated 2/11/2025 did not have documented evidence that a care plan was developed for the management of Patient 2s hypertension. The DPCS stated Patient 2s secondary diagnosis of hypertension is ongoing, and patient continues to be on medication for it. The DPCS further stated the importance of care planning patients medical history is because any medical problem could have an affect on the patients overall health or decline and being aware of it and how to care for it can dictate patients care. The DPCS also stated if the patient has an episode of high blood pressure it can affect her health like cause agitation, anxiety, discomfort, and other adverse effects.

Based on interview and record review the Hospice Agency Interdisciplinary Group (IDG) failed to document and care plan the treatment interventions for skin management for one of fourteen sample patients (Patient 1). This deficient practice had to the potential to affect the continuity of care amongst the patients care team that could have affected patients healing process. --- A review of Patient 1s ";Personal Information" document, indicated a Start of Care (SOC) date of 7/13/2024 and End of Care (EOC) date of 7/18/2024, with a primary diagnosis of Senile degeneration of brain, not elsewhere classified (cognitive/mental decline, like memory loss, confusion, agitation, mood changes or depression, in older people). During a review of Patient 1s medical record titled Comprehensive Nursing Assessment dated 7/13/2024 it was noted to be signed by the Director of Patient Care Service Designee (DPCSD). Patient 1s Comprehensive Nursing Assessment, under skin impairment assessment indicated Patient 1 to have redness to abdomen area and rectal area. During a concurrent interview and record review on 2/21/2025 at 11:42 am., with the DPCSD, Patient 1s Comprehensive Nursing Assessment dated 7/13/2024 was reviewed. The DPCSD stated and confirmed she completed and signed Patient 1s Comprehensive Nursing Assessment dated 7/13/20224. The DPCSD stated and confirmed there was no documented evidence that on that initial visit any care or treatment was applied on Patient 1s skin redness and that any education/training on patients skin treatment and management was provided to the caregiver. During a concurrent interview and record review on 2/21/2025 at 11:51 am., with the DPCSD, Patient 1s Initial Plan of Care/ Interdisciplinary Group (POC/IDG) Review for Certification period #1 dated 7/15/2024 was reviewed. The DPCSD stated and confirmed Patient 1s Initial POC/IDG did not have documented evidence of any care plans for the patient's care and that was including no care plans for the patients skin redness treatment, management and education to the caregiver. During a concurrent interview and record review on 2/21/2025 at 1:30 pm., with the DPCS, Patient 1s medical record titled Comprehensive Nursing assessment dated 7/13/2024 was reviewed. The DPCS stated and confirmed under the section Integumentary-skin other observations, the RN1s documentation was an order and did not indicate if that was what the DPCSD applied as treatment and what other interventions were done and how the patient tolerated the care. During a concurrent interview and record review on 2/24/2025 at 11:50 am with the Director of Patient Care Services (DPCS), Patient 1s POC/IDG dated 7/15/2024 and 7/16/2024 was reviewed. The DPCS stated and confirmed Patient 1s POC/IDG dated 7/15/2024 and 7/16/2024 did not have documented evidence of care plans for the management and treatment of Patient 1s skin and if any education or training was provided to the caregiver. The DPCS stated during IDG meetings the care plans are entered manually by the team during conversation of the patient, and they forgot to document it. The DPCS further stated if a care plan for a patients condition was not documented then it did not happen and can indicate the IDG did not communicate about it. The DPCS stated the importance of developing POC with IDG is to promote communication and cohesiveness of care within the patients care team.

Based on observation and interview, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to provide necessary medical supplies (suction machine [medical device that is primarily used for removing obstructions, such as mucus, saliva, blood, or secretions from a person's airway], and Yankauer [a medical device used to remove fluid and debris from the body during medical procedures]) to one of fourteen sampled patients (Patient 10). This deficient practice had the potential to result in an uncontrolled symptom, which could affect the patients quality of life. --- During a review of Patient 10s ";Personal Information", indicated a start of care (SOC) date of 11/19/2024, with a primary diagnosis of hypertensive heart disease without heart failure (is a condition where the heart is affected by high blood pressure (occurs when the force of your blood against your artery walls is too high) over time, but no heart failure). During a review of Patient 10s ";Physicians Order," the HAs physician order includes: - Order date of 11/8/2024, DME (Durable Medical Equipment), Suction Machine, indication: to remove excessive secretions (the process of segregating, elaborating, and releasing some material functionally specialized as saliva). - Order date of 11/9/2024, SN (Skilled Nurse) to do oral suctioning to remove excessive oral secretion as needed. During a joint home visit to Patient 10s residence with Registered Nurse (RN1) on 2/20/2025 at 10:30 a.m., Patient 10 was observed lying comfortably on his bed, awake, alert, and oriented to his name, place, time and events. Patient 10 was with his daughter and acted as his primary caregiver (Family Member 2/FM 2). During an interview with FM2 at 10:50 a.m., FM2 stated that the HA did not provide them with a suction machine (a medical device that removes fluids, gases, or secretions; suction machines are used to clear airways and prevent blockages that can interfere with breathing), or a Yankauer suction tip and it was not in their residence. During an interview with RN 1 at 10:52 a.m., RN 1 confirmed that suction machine was not in Patient 10s residence and stated she was not sure why Patient 10 had no suction machine available at his residence. RN 1 stated that it was important that suction machine was readily available to use if visiting nurse has to suction Patient 10s excessive secretions. During an interview with the Director of Patient Care Services (DPCS) on 2/21/2025 at 2:30 p.m., the DPCS stated that suction machine was part of standard orders for the HAs patients. The DPCS stated that standard order means they were ordered for all of the HAs patients. The DPCS stated if suction machine was ordered by the physician, then the HA needed to provide them for the patients, even though the patient might not need them immediately. The DPCS stated he did not know why the patients never received the supply. The HA did not provide a policy and procedure on medical supplies and appliances necessary for the patient as requested by the survey team on 2/24/2025.

Based on observation, interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to follow physicians order for one of fourteen sampled patients (Patient 10) by failing to: a) Ensure a blood sugar, and a blood pressure log were maintained according to the plan of care to monitor and/or assess effectiveness of current and new medication/treatment as per physician orders to help identify patterns, understand how medications help to prevent complications. b) Ensure that Registered Nurse 1 (RN 1) provided teaching to Patient 10s family member/caregiver (FM2) regarding the importance of documenting Patient 10s blood sugar levels and blood pressure readings, potentially leading to poor quality of care This deficient practice resulted in Patient 10s blood sugar and blood pressure readings unmonitored, that could affect the effectiveness of current medications and treatment. --- During a review of Patient 10s ";Personal Information", indicated a start of care (SOC) date of 11/19/2024, with a primary diagnosis of hypertensive heart disease without heart failure (is a condition where the heart is affected by high blood pressure (occurs when the force of your blood against your artery walls is too high) over time, but no heart failure). During a review of Patient 10s POC (Plan of Care, consists of different patient goals, nursing and allied health assessment and interventions to help attain those goals, and expected outcomes aligned with the patient's needs)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 1/28/2025, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus three PRN (pro re nata, which means ";as needed") visits for pain, symptom management, and to promote comfort, the Master of Social Work (MSW) to visit once a month and one PRN visit for psychosocial issues, needs and concerns, Spiritual Counselor (SC) to visit one time then on every recertification for spiritual issues and concerns and Hospice Aide (HA) to visit twice a week as needed for personal care, home making, and to promote comfort. Upon further review of Patient 10s IDG/POC, it indicated under Cardiovascular (pertains to the heart and blood vessels) and Endocrine (a network of glands that produce hormones that help regulate the body's functions) with goals that include: Patient/caregiver will verbalize/express understanding of medication/treatment orders and side effects by one week at a time or by next SN (skilled nurse) visit, and an intervention that includes: Instruct patient/caregiver regarding new medication/treatment order and side effects and monitor/assess effectiveness of current and new medication/treatment. During a review of Patient 10s Current Treatment/Medication/DME (Durable Medical Equipment, medical equipment that is used repeatedly and is primarily used for medical purposes), the Current Treatment/Medication/DME List indicated that the HAs physician ordered the following medications for Patient 10: -Order date of 11/8/2024, Insulin Glargine (A long acting insulin drug used to control the amount of sugar in the blood of patients with diabetes, a chronic disease where the body does not produce or use insulin properly, Insulin is a hormone that helps glucose (sugar) from food get into the cells for energy, without enough insulin or proper insulin use, glucose builds up in the bloodstream, leading to high blood sugar levels), dosage: 20 units, route: subcutaneous (the layer of tissue that underlies the skin), frequency: at bedtime-routinely, hold if blood sugar below 100mg (milligram, unit of measurement)/dl (deciliter, unit of measurement), indication: Diabetes -Order date of 2/17/2025, Amlodipine Besylate ( to treat high blood pressure or hypertension, a condition in which the pressure of the blood in the arteries is too high), strength: 5mg, dosage: 1 tablet, route: by mouth, frequency: once daily-routinely, hold for SBP (systolic blood pressure, the pressure in the arteries when the heart contracts and pumps blood) below 110 and HR (heart rate) below 60 BPM (beat per minute). -Order date of 11/8/2024, Lisinopril (to treat high blood pressure or hypertension, a condition in which the pressure of the blood in the arteries is too high), strength: 10 mg, dosage: 1 tablet, route: by mouth, frequency: two times a day, hold for SBP (systolic blood pressure, the pressure in the arteries when the heart contracts and pumps blood) below 100 and HR (heart rate) below 60 BPM (beat per minute). During a joint home visit to Patient 10s residence with Registered Nurse 1 (RN 1) on 2/20/2025 at 10:30 a.m., observed Patient 1 awake, alert, and oriented, comfortably resting on his bed, lives in a private residence with his daughter (Family Member 2 /FM 2), who acted as the patient's caregiver. During the home visit, at 10:50 a.m., a medication review was performed with RN 1, which include the current medications of glargine insulin and amlodipine. According to FM 2, all the medications that reviewed were all the medications that Patient 10 was taking. FM2 stated that she followed the instructions in administering the insulin. FM2 stated that she checks her fathers (Patient 10) blood sugar using the glucometer, and if it is under 100 mg/dl reading, stated she does not give the insulin to his father and will inform the HA. FM2 stated that her fathers blood sugar is always above 100mg/dl and there were no instances that her fathers blood sugar was below 100mg/dl. FM2 stated that she does not write down the blood sugar readings of her father and she is unsure and if the HA provided a log to write down her fathers blood sugar readings. FM2 stated that she also gives her fathers medications including the medications for blood pressure (amlodipine and lisinopril). FM2 stated that she checked her fathers blood pressure (BP) before giving the medication and if the above number (SBP) is below110 for amlodipine, SBP below 100 for lisinopril, and the heart rate is below 60, she will not give the medication. FM 2 stated that her fathers BP readings and heart rate readings were always above the given parameters, and she does not write down her fathers BP readings for record. FM2 stated that she is unsure if there were log sheets provided by the HA nurse to write down the BP and blood sugar readings of her father. FM2 stated that she did not remember if she was taught by the HA nurses to write down the blood sugar and blood pressure readings of her father. During an interview with RN 1 at 11 a.m., stated she provided teachings to FM2 regarding the parameters and to write down the blood pressure and blood sugar readings of Patient 10, but unsure if she documented that teachings were provided to Patient 10 and/or FM2. RN 1 stated that FM2 was supposed to log in the readings of Patient 10s daily blood sugar and blood pressure. RN 1 stated that she is unsure if HA provides BP/blood sugar readings log sheets to patients and/or caregivers. RN 1 stated that it is important that patient and/or caregiver writes down the daily BP/blood sugar readings to be able to monitor effectively if current medications are working and if there any changes and improvement. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 2/21/2025 at 1:30 p.m., the DPCS reviewed Patient 10s Current Treatment/Medication/DME List, POC/IDG Review dated 1/28/2025, Visit Note RN dated 1/11/2025 and 1/23/2025. The DPCS stated the HA did not maintain a blood sugar log and blood pressure log for Patient 10, stated but FM2 should maintain one and the HA visiting nurse should reminded and educate them. The DPCS stated he was not aware that there was no blood sugar log and blood pressure log maintained for Patient 10. The DPCS stated that verbal report by FM2 to HA visiting nurses was not an adequate monitoring. The DPCS stated there could be negative outcome of not properly monitoring Patient 10s blood sugar and blood pressure, such as the blood sugar or blood pressure could be too low or too high, and the HA visiting nurses, and the physician would not be aware. The DPCS stated that RN 1 should have documented the blood sugar reading and blood pressure reading maintenance records teachings and provided to Patient 10 and/or FM2. Per DPCS, the HA staff should have instructed to maintain a blood sugar and blood pressure logs as part of the overall disease management for Patient 10. During a review of the HAs policy and procedure, titled ";The Plan of Care," revised November 2021, the policy and procedure indicated that a written, individualized, patient and family/caregiver plan of care would be established and maintained for everyone admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care.

Based on interview and record review the hospice failed to maintain RN supervisory visits for two of 14 sampled patients (Patient 6 and Patient 8). This failure left Patient 6 and Patient 8 without supervised HHA services that were being provided by the hospice staff. --- During a review of patient 6s ";admission record it indicated a start of care (SOC) date of 8/1/24 with a terminal diagnoses of Hypertensive Heart Disease (cardiac complications of high blood pressure) During a review of patient 6s ";plan of care/IDG review dated 1/28/25 it indicated the frequency of visits of skilled nurses (SN) is 2 per week and HHA visits of 2/week During a review of Patient 6s home visits it indicated no supervisory visits were made between the following dates for Patient 6: 1) 8/6/24 – 8/27/24 (21 days) 2) 9/12/24 – 10/7/24 (23 days) During a review of Patient 8s ";admission record it indicated a start of care (SOC) date of 7/30/24 with a terminal diagnoses of Heart Failure (severe failure of the heart to function properly) During a review of Patient 8s ";plan of care/IDG review dated 2/11/25 it indicated the frequency of visits of skilled nurses (SN) is 2 per week and HHA visits of 3/week During a review of Patient 8s home visits it indicated no supervisory visits were made between the following dates for Patient 8: 1) 8/26/24 – 9/11/24 ( 16 days) 2) 9/13/24 – 10/9/24 ( 24 days) 3) 11/8/24 – 12/4/24 (26 days) During a phone interview conducted on 2/21/25 at 8:35 am., with RN2 he stated he is the RN for Patient 6 and is responsible for providing the supervisory visits every 14 days. When provided with those dates he stated that those visits should be documented as missed visits. RN2 was able to acknowledge that supervisory visits were not made between those dates. When asked why is that important, he stated to ensure that the patient is receiving proper care by the HHA and LVN and this was not done on those dates provided. During a review of the agencys policy entitled ";Hospice Aide Supervisory Visits" with a revised date of November 2021 it indicated the purpose of this policy is to establish guidelines for the responsibilities and the frequency of supervisory visits for hospice aide/homemaker personnel. The hospice RN case manager will conduct supervisory visits to the patients residence at regular intervals. They must be conducted no less frequently than every 14 days. The case manager will be responsible for providing written instructions to ensure compliance with the plan of care.

Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation on Clinical Records was met as follows: --- 1. The HA failed to complete clinical notes that included patient/patients caregiver education, training and missed nursing visits for four of fourteen sampled patients (Patient 2, Patient 7, Patient 8 and Patient 10). (Refer to L672). 2. The HA failed to ensure a completed copy of written information regarding advance directive (a legal document that outlines person's wishes in the event an individual is unable to express wishes for healthcare and treatments) policies and descriptions for two of fourteen sampled patients (Patient 2 and Patient 10). (Refer to 677). 3. The HA failed to ensure an accurate skin assessment was documented to one of fourteen sampled patients (Patient 10). (Refer to L679). The cumulative effects of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Clinical Records to ensure patients clinical records are completed, updated and accurately documented.

Based on interview and record review the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the patients' record contained completed skilled nurse (SN) nursing visit notes and submitted in a timely manner, to reflect the care and assessment provided for two of fourteen sample patients. (Patient 1, and Patient 2). This failure resulted in the patients incomplete clinical record that could lead to misinformation and non-continuity of care and services provided to the patients. --- A. A review of Patient 1s ";Personal Information" document, indicated a Start of Care (SOC) date of 7/13/2024 and End of Care (EOC) date of 7/18/2024, with a primary diagnosis of Senile degeneration of brain, not elsewhere classified (cognitive/mental decline, like memory loss, confusion, agitation, mood changes or depression, in older people). A review of Patient 1s medical record titled, Plan of Care/ Interdisciplinary Group (POC/IDG) Review for Certification period #1 with start date of 7/15/2024, indicated an order, with start date of 7/13/2024, for Certified Hospice Aide (CHHA) to visit 3 times per week starting 7/15/2024 for personal care, home making, and to promote comfort per Registered Nurse (RN) assignment. During a review of Patient 1s EMR indicated the CHHA did not submit a weekly nursing note for week of 7//15/2024 to 7/18/2024. During a concurrent interview and record review on 2/21/2025 at 12:12 pm with the DPCS, Patient 1s EMR was reviewed. Patient 1s EMR indicated there was no submission of a CHHA visit note, under ";History of HA visits" section. The DPCS stated and confirmed Patient 1 had an order for CHHA visits 3 times per week to start on 7/15/2024. The DPCS stated and confirmed there was no documented evidence of a CHHA visit for Patient 1 the week of 7/15/2024 to 7/18/2024, and no documented missed visit note or communication note. The DCPS stated the HA had been focusing on communicating with Patient 1s Family Member and listening to her concerns, they wanted to find a CHHA to meet Patient 1s Family Member needs. The DPCS further stated the importance of following through with physician order to provide patient with CHHA as ordered, is because Patient 1 had skin issues and lack of mobility. B. A review of Patient 2s ";Personal Information" document, indicated a SOC date of 6/19/2023, with a primary diagnosis of Alzheimers disease (a disease characterized by a progressive decline in mental abilities). A review of Patient 2s medical record titled, Plan of Care/ Interdisciplinary Group (POC/IDG) Review for Certification period #9 with start date of 12/31/2024, indicated an order for Skilled Nurse (SN) visit one time a week and three PRN visits. During a review of Patient 2s EMR indicated the SN did not submit a weekly nursing note for week of 12/29/2024–1/4/2025. During a concurrent interview and record review on 2/21/2024 at 1:45 pm with the DPCS, Patient 2s EMR was reviewed. Patient 2s EMR indicated there was no documented SN name on Patient 2s visits calendar for the week of 12/29/2024 to 1/4/2025. The DPCS stated and confirmed when there is no SN name on the patients visits calendar it means there was no SN visit completed for that week The DPCS stated and confirmed there was no documented visit for patient 2, for the week of 12/29/24 to 1/4/25 from the SN and there was no missed visit documentation in the communication log section. The DPCS further stated and confirmed Patient 2s Plan of Care (POC) was not being followed since the SN did not visit, once per week, as indicated on the POC. During a review of the HA's Policy and Procedure (P&P) titled, Missed Visits with a revised date of November 2021, indicated, "2. If a visit is missed and not rescheduled the clinician will" B. Document in the patient's clinical record the following information: 1. Patient name 2. Date and type of visit that was missed 3. Reason for the missed visit 4. Description of any unmet needs and how the patient's needs were met 5. Any other follow-up needed 6. Other person(s) that were notified of the missed visit 7. Signature of staff members reporting the information".

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure a completed copy of written information regarding advance directive (a legal document that outlines person's wishes in the event an individual is unable to express wishes for healthcare and treatments) policies and descriptions for two of fourteen sampled patients (Patient 2 and Patient 10). This failure had the potential to result in the patients family and/or caregivers not knowing what the patients medical decisions are, which can result in psychological distress to the patient/patients family/caregiver. --- b. During a review of Patient 10s ";Personal Information", indicated a start of care (SOC) date of 11/19/2024, with a primary diagnosis of hypertensive heart disease without heart failure (is a condition where the heart is affected by high blood pressure (occurs when the force of your blood against your artery walls is too high) over time, but no heart failure). During a review of Patient 10s POC (Plan of Care, consists of different patient goals, nursing and allied health assessment and interventions to help attain those goals, and expected outcomes aligned with the patient's needs)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 1/28/2025, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus three PRN (pro re nata, which means ";as needed") visits for pain, symptom management, and to promote comfort, the Master of Social Work (MSW) to visit once a month and one PRN visit for psychosocial issues, needs and concerns, Spiritual Counselor (SC) to visit one time then on every recertification for spiritual issues and concerns and Hospice Aide (HA) to visit twice a week as needed for personal care, home making, and to promote comfort. During a home visit observation on 2/20/2025, at 10:30 a.m., to Patient 10s residence, with Registered Nurse (RN 1), Patient 10 was observed resting comfortably on his bed. Patient 10 is alert, awake and oriented to his name, time, place and events. During a concurrent review of Patient 10s hospice folder with RN1, The folder had the name of the agency, inside of the folder indicated no copy of Patient 10s POLST (Physician Orders for Life-Sustaining Treatment, is a written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness). During interview with RN1, RN1 confirmed and stated she was unaware that Patient 10s POLST is not inside the hospice folder or anywhere in his residence. RN 1 stated that the POLST should be with the patient at all times and it should have been check and processed by the social worker. RN 1 stated that if Patient 10s heartbeat stops, then a CPR must perform since the POLST was not with the patient. During an interview at 10:45 a.m., with Patient 10s daughter/caregiver (Family Member 2/FM2), FM2 stated she is the authorized representative of her father (Patient 10) and does not remember if they have a copy of the POLST. FM2 stated she does not remember if a POLST was discussed and explained to them by the HA. During a concurrent record review and interview on 2/22/2025, at 10:45 a.m., with the Director of Patient Care Services (DPCS), indicated Patient 10s POLST was completed but was unsure why a copy was not provided and not in Patient 10s hospice folder or residence. DPCS stated that copy of POLST should have been provided to Patient 10s hospice agencys home folder or with their possession for future reference to define the code status of the patient. During a telephone interview on 2/24/2025, at 11:38 a.m., with the Master of Social Work (MSW 2), MSW2 stated that a complete POLST should have been placed to Patient 10s hospice folder for future reference and to define patients code status. MSW2 stated that a completed and readily available copy of POLST is very important for the healthcare providers future reference when Patient 10s medical condition decline or if his heartbeat stops and to avoid confusion. During a review of the HAs policy and procedure entitled, ";Do Not Resuscitate/Do Not Intubate Orders", revised November 2021, the policy and procedure indicated that a written Do Not Resuscitate (DNR) order signed by the patients physician (or authorized independent practitioner) must be on file in the patients clinical record and admission folder in the patients home and D.) A copy of the DNR/DNI order will be kept in the patient's home. A. A review of Patient 2s ";Personal Information" document, indicated a SOC date of 6/19/2023, with a primary diagnosis of Alzheimers disease (a disease characterized by a progressive decline in mental abilities). A review of Patient 2s medical record titled, Plan of Care/ Interdisciplinary Group (POC/IDG) Review for Certification period #10 with start date of 2/11/2025, indicated for Certified Hospice Aide (CHHA) to visit 2 times per week and Skilled Nurse (SN) to visit 1 per week with three as needed (PRN) visits. During a joint home visit on 2/19/2025 at 12:16 pm, with Registered Nurse 1 (RN1) at Patient 2s home, Patient 2 was observed awake and alert to self and location, able to answer simple questions and sitting up on her wheelchair. Patient 2 was observed with her right and left arms contracted (permanent tightening of the muscles, tendons, skin and nearby tissue that cause the joints to shorten and become stiff) in a 90-degree angle. During the visit on 2/19/2025 at 12:46 pm with Registered Nurse 1 (RN1) at Patient 2s home, Patient 2s Hospice Agency (HA) binder was reviewed. The HA binder indicated there was no POLST form for Patient 2. RN1 stated and confirmed Patient 2s HA binder did not have the patients original POLST form. RN1 stated she did not know where the POLST form was. Patient 2s caregiver stated provided a second HA binder for Patient 2 and stated it was the old binder. The caregiver and RN1 stated and verified there were no POLST forms in both binders presented. During an interview on 2/21/2025 ay 12:45 pm with the Medical Social Worker (MSW), the MSW stated all HA patients should be provided with the original copy of their POLST in their HA binder or posted in their home in an accessible and viewable wall for any medical emergencies. The MSW also stated all POLST are to be signed by the patient or responsible party and the doctor.

The HA failed to conduct an accurate skin assessment and update the comprehensive assessment that reflected the skin abnormality in patients both groin areas for one out of fourteen sampled patients (Patient 10). This deficient practice had the potential to result an inaccurate assessment leading to the delay of treatment and intervention. --- During a review of Patient 10s ";Personal Information", indicated a start of care (SOC) date of 11/19/2024, with a primary diagnosis of hypertensive heart disease without heart failure (is a condition where the heart is affected by high blood pressure (occurs when the force of your blood against your artery walls is too high) over time, but no heart failure). During a review of Patient 10s POC (Plan of Care, consists of different patient goals, nursing and allied health assessment and interventions to help attain those goals, and expected outcomes aligned with the patient's needs)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 1/28/2025, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus three PRN (pro re nata, which means ";as needed") visits for pain, symptom management, and to promote comfort, the Master of Social Work (MSW) to visit once a month and one PRN visit for psychosocial issues, needs and concerns, Spiritual Counselor (SC) to visit one time then on every recertification for spiritual issues and concerns and Hospice Aide (HA) to visit twice a week as needed for personal care, home making, and to promote comfort. During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 2/24/2025 at 12:20 p.m., the clinical records of Patient 10 indicated the following: -Patient 10s clinical record titled ";Visit Note RN (Registered Nurse)," dated 1/11/2025, indicated on the ";Integumentary-Skin" section, documented as – none to rash (An area of the skin that has changes in texture or color and may look inflamed or irritated), none to wounds (an injury to the body that can involve a cut, tear, or break in the skin or tissue), none to ulcers/bed sores ( a sore or damaged area on the skin that develops when pressure is applied to the same spot for a long time), none to other symptom, comments were left blank, and the ";Narrative" section indicated a documentation ";noted with redness on his (Patient 10) groin area." -Patient 10s clinical record titled ";Visit Note RN (Registered Nurse)," dated 1/23/2025, indicated on the ";Integumentary-Skin" section, documented as – none to rash, none to wounds, none to ulcers/bed sores, none to other symptom, comments were left blank, and the ";Narrative" section indicated a documentation ";patient was noted to be cooperative upon visit and redness on the groin is noted with improvement." - Patient 10s clinical record titled ";Visit Note LVN (Licensed Vocational Nurse)," dated 1/27/2025, indicated on the ";Integumentary-Skin" section, documented as – none to rash, none to wounds, none to ulcers/bed sores, none to other symptom, comments were left blank, and the ";Narrative" section indicated a documentation ";Redness on the groin areas are resolving." DPCS confirmed and stated that based on the clinical records reviewed, the skin assessments of the visiting nurses for Patient 10 was inaccurate and inconsistent. DPCS stated that both the Integumentary-Skin section and narrative documentations of nurses for patients should be consistent and reflect the status of the patient to avoid confusion among the healthcare team or possible delay in providing care for patients. During a review of the HAs policy and procedure titled ";Comprehensive Assessment," dated November 2021, the procedure indicated that during the comprehensive patient assessment, all baseline data and other relevant information will be documented: G. A physical assessment, including blood pressure, temperature, pulse, respiration, skin, and other relevant data related to physical findings and the patients terminal illness. During a review of the HAs policy and procedure titled ";Clinical/Service Data Collection," revised November 2021, the policy indicated that documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided.