Every finding on record at Vitas Healthcare Corporation of Florida

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measures are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review, observation, and interview. Agency policy, "Long Term Care Facility" (dated 12/03/2025) stated in part, "General Instructions: LTC Visit Overview...Review the patient chart...Check to see if there are any new orders. Review the LTC Plan of Care (POC): Are there any changes? Is it consistent with the (hospice) POC...Coordinate the changes in the POC...with the appropriate facility staff...Professional Management: (hospice) is responsible for the professional management of all hospice services provided to LTC facility patients...Ongoing assessment, monitoring, and coordinating care..." 1 of 1 (100%) home visits observed and clinical records reviewed for a patient residing in a nursing facility (NF), the agency did not ensure the comprehensive assessment included a drug profile listing the patient's current medications. HOME VISIT 3/CLINICAL RECORD 3: The patient elected hospice care on 10/15/2025 with a primary diagnosis of cerebral atherosclerosis. The patient resided in a nursing facility. During the home visit with the Registered Nurse (RN)(Personnel Record 5) on 12/17/2025, a printed medication profile from the facility's electronic medical record (EMR) was obtained. A review of the NF medication profile and the hospice medication profile revealed medications appeared on the NF medication profile that were listed as discontinued as of 10/20/2025 in the hospice medication profile: amlodipine besylate oral tablet 10mg, one tablet by mouth once daily for hypertension (start date 08/14/2025); metformin hcl oral tablet 500mg, one tablet by mouth once daily for diabetes melilites (start date 08/14/2025); and valsartan oral tablet 160mg, one tablet by mouth once daily for hypertension. In addition, the hospice medication profile documented Zofran 4mg oral disintegrating tablet, one tablet by mouth every 6 hours as needed (PRN) for nausea or vomiting (start date 11/04/2025), which did not appear on the NF medication profile. The RN returned to the NF on 12/17/2025 and documented in the visit note, "Medication list discussed with Dr. (hospice MD) and Dr. (attending MD). Orders received to profile Valsartan, Metformin...FN (facility nurse) confirms patient continues to receive Metformin and Valsartan. Order given to RN, reviewed orders, and paper order given..." The hospice and NF medication profiles were updated to include the patient's Metformin and Valsartan. Amlodipine was discontinued in the NF and the hospice medication profiles. The NF updated medication profile did not document the PRN Zofran order. During a joint review of the NF and hospice medication profiles and an interview on 12/18/2025, the National Patient Care Administrator (NPCA) confirmed a discrepancy between the active medications on the medication profiles. The NPCA stated that the nurse returned to the facility the same afternoon to bring the two lists into compliance and that she should check and compare NF and hospice medications at her visits.

It is required that the nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy "Frequency" (dated 11/10/2025) stated in part, "Frequency is part of the Plan of Care (POC)...POC Frequency is documented on...Addendum to the General Plan of Care...Frequency is based on the IDG/patient care plan week, starts the day after team meeting, ends on the next team meeting...Frequency is individualized based on assessed patient and family needs...Declined Visits...Document the declination...in the clinical record. Communicate the declination with the IDG as appropriate..." In 4 of 19 (21%) clinical records reviewed, the agency did not ensure that nursing care and services were provided in accordance with the plan of care. CLINICAL RECORD 7: The patient elected hospice care on 01/08/2025 with a primary diagnosis of Huntington's disease. For the benefit period from 11/04/2025 to 01/03/2026, the plan of care ordered the Skilled Nurse (SN) to visit twice the week of 11/09/2025. One visit was completed on 11/13/2025. A clinical record review revealed no second visit completed and no documented missed visit. For the week of 11/23/2025, the plan of care ordered SN services once a week. No visit was completed, and no missed visit was documented. CLINICAL RECORD 8: The patient elected hospice care on 08/12/2025 with a primary diagnosis of end-stage renal disease. For the benefit period from 11/10/2025 to 02/08/2026, the plan of care ordered SN services twice a week, the week of 11/30/2025. One visit was completed on 12/04/2025 for the week of 11/30/2025. A clinical record review revealed no second visit completed and no documented missed visit. CLINICAL RECORD 9: The patient elected hospice care on 06/30/2025 with a primary diagnosis of chronic systolic congestive heart failure. For the benefit period from 09/28/2025 to 12/27/2025, the plan of care ordered SN services twice a week, the week of 11/16/2025. One visit was completed on 11/19/2025 for the week of 11/16/2025. A clinical record review revealed no second visit completed and no documented missed visit. CLINICAL RECORD 14: The patient elected hospice care on 08/08/2025 with a primary diagnosis of pulmonary fibrosis. For the benefit period from 11/06/2025 to 02/04/2025, the plan of care ordered SN services three times, the week of 11/16/2025. Two visits were completed on 11/17/2025 and 11/19/2025 for the week of 11/16/2025. A clinical record review revealed no third visit completed and no documented missed visit. During a joint clinical record review and interview on 12/19/2025, the National Patient Care Administrator (NPCA) confirmed a discrepancy between the ordered number of visits and the actual visits documented in clinical records 6, 7, 8, 9, and 14. No documented reason was found for why the visit frequencies had not been met, although the NPCA stated it was difficult to track in the electronic medical record system and in the scheduling system the hospice utilizes.

It is required that medical social services are provided by a qualified social worker: per the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy "Frequency" (dated 11/10/2025) stated in part, "Frequency is part of the Plan of Care (POC)...POC Frequency is documented on...Addendum to the General Plan of Care...Frequency is based on the IDG/patient care plan week, starts the day after team meeting, ends on the next team meeting...Frequency is individualized based on assessed patient and family needs...Declined Visits...Document the declination...in the clinical record. Communicate the declination with the IDG as appropriate..." In 1 of 12 (8%) clinical records reviewed for patients receiving medical social services, the agency did not ensure that services were provided per the plan of care. CLINICAL RECORD 6: The patient elected hospice care on 10/19/2024 with a primary diagnosis of liver cell carcinoma. For the benefit period from 10/15/2025 to 12/14/2025, the plan of care ordered that the Social Worker (SW) visit the patient once the week of 11/20/2025. A clinical record review revealed that no visit was made and no missed visit was documented. During a joint clinical record review and interview on 12/19/2025, the National Patient Care Administrator (NPCA) confirmed a discrepancy between the ordered number of visits and the actual visits documented in clinical record 6. No documented reason was found for why the visit frequency had not been met, although the NPCA stated it was difficult to track in the electronic medical record system and in the scheduling system the hospice utilizes.

It is required that a hospice aide provides services: ordered by the Interdisciplinary Group. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy "Frequency" (dated 11/10/2025) stated in part, "Frequency is part of the Plan of Care (POC)...POC Frequency is documented on...Addendum to the General Plan of Care...Frequency is based on the IDG/patient care plan week, starts the day after team meeting, ends on the next team meeting...Frequency is individualized based on assessed patient and family needs...Declined Visits...Document the declination...in the clinical record. Communicate the declination with the IDG as appropriate..." In 4 of 14 (29%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide provided services ordered by the Interdisciplinary Group (IDG). CLINICAL RECORD 6: The patient elected hospice care on 10/19/2024 with a primary diagnosis of liver cell carcinoma. For the benefit periods from 10/15/2025 to 12/14/2025 and 12/14/2025 to 02/11/2026, the plans of care ordered for the Hospice Aide to visit the patient one time during the weeks of 12/11/2025 and 12/15/2025. No visit was completed either week, and no missed visits were documented. CLINICAL RECORD 8: The patient elected hospice care on 08/12/2025 with a primary diagnosis of end-stage renal disease. For the benefit period from 11/10/2025 to 02/08/2026, the plans of care ordered HA services twice a week for the weeks of 11/16/2025 and 12/07/2025. One visit was completed on 11/19/2025 for the week of 11/16/2025; no second visit was completed, and no missed visit was documented. One visit was completed on 12/10/2025 for the week of 12/07/2025; no second visit was completed, and no missed visit was documented. CLINICAL RECORD 9: The patient elected hospice care on 06/30/2025 with a primary diagnosis of chronic systolic congestive heart failure. For the benefit period from 09/28/2025 to 12/27/2025, the plan of care ordered HA services twice the week of 11/02/2025. One visit was completed on 11/06/2025; no second visit was completed, and no missed visit was documented. CLINICAL RECORD 14: The patient elected hospice care on 08/08/2025 with a primary diagnosis of pulmonary fibrosis. For the benefit period from 08/08/2025 to 11/06/2025 and from 11/06/2025 to 02/04/2025, the plans of care ordered HA services three times a week for the week of 10/19/2025. One visit was completed on 10/20/2025; no second or third visit was completed, and no missed visits were documented. For the week of 10/26/2025, the plan of care ordered HA services twice a week. One visit was completed on 10/29/2025; no second visit was completed, and no missed visit was documented. For the week of 11/02/2025, the plan of care ordered HA services five times a week. Three visits were completed on 11/03/2025, 11/04/2025, and 11/06/2025; no fourth or fifth visits were completed, and no missed visits were documented. For the week of 11/23/2025, the plan of care ordered HA services twice a week. One visit was completed on 11/25/2025; no second visit was completed, and no missed visit was documented. During a joint clinical record review and interview on 12/19/2025, the National Patient Care Administrator (NPCA) confirmed a discrepancy between the ordered number of visits and the actual visits documented in clinical records 6, 8, 9, and 14. No documented reason was found for why the visit frequencies had not been met, although the NPCA stated it was difficult to track in the electronic medical record system and in the scheduling system the hospice utilizes.

It is required that the hospice inpatient facility has documented and dated written reports of Life Safety Code fire drills at varied times on all shifts. This standard was not met as evidenced by document review, interviews and observations. During an observation tour of an in-patient unit (IPU), it was revealed that the hospice did not meet the requirement in documenting the evaluation of the procedures implemented upon completion of fire drills. Interviews were conducted with the Maintenance Supervisor, the Assistant Maintenance Supervisor, the Regional Hospice Director, the Hospice Area Administrator, and the Inpatient Unit Manager. No supporting documentation per the regulation was presented for fiscal years 2020, 2021, or 2022 evidencing documentation efforts (except for the hospital date and time of the drills), hospice staff participation in the elements and evaluation of the procedural process of the drill. Nor was there documented evidence for the hospice staff who participated in the drills. Currently, the Maintenance Department tracks the date and time of fire drills per month/per quarter for the hospital system with which the hospice contracts under their professional relationship. Further conversation revealed during interviews that the Hospice Inpatient staff follows the fire drill protocols when the alarm sounds initiating a drill. This was confirmed by the Inpatient Manager. The hospice staff is unaware of the scheduling of the drills, or the type of drills being conducted by the Maintenance Department. Additionally, it was discovered that there was no documentation of who participated in the drill, or what role and duties those who participated were assigned. There was no evidence of evaluation of these drills post-event, for purposes of quality control. These post -drill evaluations are not being conducted to comply with policy item B. During an observational tour of an IPU, It was revealed that the hospice did not meet the requirement in documenting the evaluation of the procedures implemented upon completion of fire drills. Interviews were conducted with the Maintenance Supervisor, the Assistant Maintenance Supervisor, the Regional Hospice Director, the Hospice Area administrator, and the Inpatient Unit Manager. No supporting documentation per the Regulation was presented for fiscal years 2020, 2021, or 2022 showing documentation efforts (except for the hospital date and time of the drills), of the Hospice Staff participation in the elements/evaluation of the procedural process of the drill. Nor was there documented evidence for the Hospice Staff who participated in the drills. Currently, the Maintenance Department tracks the Date and Time of fire drills per month/per quarter for the hospital system with which the hospice contracts the hospital under their professional relationship. Further conversation revealed during interviews that the Hospice Inpatient staff follows the Fire Drill protocols when the alarm sounds initiating a drill. This was confirmed by the Inpatient Manager. The Hospice Staff is unaware of the scheduling of the drills, or the type of drills being conducted by the Maintenance Department. Additionally, it was discovered that there was no documentation of who participated in the drill, or what role and duties those who participated were assigned. There was no evidence of evaluation of these drills post-event, for purposes of quality control. These Post Drill evaluations are not being conducted to comply with policy item B. The Policy Item, "Disaster Preparedness for the Hospice Inpatient Care Centers" read in part"... under Statement of Policy Item B, 1. The staff person discovering the fire will do the following: a. If the fire is small, safe to approach, and involves a person's clothing or bed, smother it with a blanket, pillow, etc. b. Call for assistance from other staff members. c. Call 911, identifying the self, address of IPC location, and reason for calling. d. Remove patients from immediate danger out of the room and close the door, then take them to a safe area behind the nearest fire door. Go to the nearest Red Fire Alarm box and pull the lever. 2. After 911 has been called and the alarm has sounded, the staff member will return to the fire site. a. If the fire is small and confined to the area where it started, for example, a waste paper basket, use a nearby object to smother the fire or a fire extinguisher to contain the fire. The person fighting the fire must consider personal safety at all times. If the fire, heat, or smoke endangers the person using the fire extinguisher should stop trying to fight the fire and move out of the fire area. b. If the fire has spread from where it has originated, if it cannot be contained with a fire extinguisher, or if smoke is filling the area: 1) Leave the door closed. Close all other doors. 2) Continue to evacuate patients within the fire zone to the nearest safe area behind fire doors. 3) If the patient is on oxygen: a) Turn off 02 in the patient's room. b) Disconnect 02 temporarily until the patient has quickly been moved to a safe area. Use portable 02 tanks as appropriate. 4) A staff member will be assigned to call the Clinical Manager or the Manager on Call. The manager will report to the IPC. 5) Staff will evacuate patients outside of the Residence if the situation warrants. Remove patients to a safe distance of 75-100 feet (to the middle of the parking lot). 6) Staff will evacuate patients at the Care Centers in accordance with the facility's policy. 7) The RN on duty (or designee) will: a) Assign staff to remain with patients, reassure them, and maintain close observations of them until the emergency is over. b) Ask visitors that are present to remain with the patient throughout the emergency. c) Shut off all 02 valves at the Residence. d) Make sure all doors are closed and the lights are on. If possible to do so without risk, the Care Team Coordinator (CTC) will remove the patient's medical records to a safe area. e) After the arrival of the fire department, report to the officer in charge and await further orders. 8) In the event of inclement weather or a need for sustained periods of an evacuation all patients will be taken to the nearest shelter until the fire department allows re-entry to the Hospice Residence or arrangements can be made to transfer patients to local inpatient beds. 9) When the fire is extinguished, the fire department will give a clear signal to return patients back to the Residence. Do not bring or let any patient return until this signal is given.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over-the-counter (OTC) drugs. The medication review process includes the identification of the following: The effectiveness of drug therapy, drug side effects, actual or potential drug interactions, and duplicate drug therapy. The assessment includes evidence that common side effects of medication in hospice populations are anticipated, and as appropriate, preventive measures are implemented to manage the side effects. This standard was not met as evidenced by a review of clinical records. In 1 of 20 (5%) records, it was revealed that the agency had failed to update the medication profile with a complete and updated record reflecting current medications. Clinical Record 13: The Start of Care (SOC) episode dated 12/8/2023 through 3/7/2023 includes the following diagnoses: CHF (congestive heart failure), HTN (hypertension), CAD (coronary artery disease), and Oxygen at 3 L per NC (liters per nasal cannula). The client has a condom catheter to bedside drainage. The Skilled Nurse (SN) visit documented a ”Leaky condom catheter” on 12/9/2023. During the visit, the patient’s wife indicated that the patient had not had a BM in 2 weeks. The RN documented that there had been Lactulose in the home and told the patient to restart Lactulose once a day. Further documentation revealed that on 12/10/2022, the wife called again about condom catheter issues and agreed to foley catheter for the patient. The Gastrointestinal section of that visit note was left blank. By 12/12/2023, the LMSW, made a visit and documented that the patient is eating better but still has “constipation issues.” The SN visit note on 12/13/022, documented, (during wound care and catheter care) "ordered Z-Pak. Last BM 11/29/2022, with abdomen distended, and tinkling bowel sounds.” Finally, on 12/15/2022, the RN narrative note documented “Abdomen distended, no BM since admission, has been taking Lactulose once a day but has not been taking Senna. The RN documented Lactulose 10 g/15 ml, 30 CC 3 times a day, and Senna two times a day, 50 mg 8.6 oral tablets, 1 tab 2 times a day". Further investigation revealed that the RN visit dated 12/9/2022 failed to update the medication profile with the daily Lactulose.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as. Hand hygiene; [and] safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids. This standard was not met as evidenced by document review, interviews and observation on home visits. The policy titled "Infection Control- Hand Hygiene", updated 1/1/2023, version #3, states in relevant parts, "The hospice follows hand hygiene guidelines recommended by the Centers for Disease Control and the World Health Organization." Item # 1 of the policy states in part that "Hospice staff must wash hands before touching the patient." In addition, the policy titled "Care Provider Bag Technique", updated 1/2023, version #3 states in part, "All/direct providers of care will have a designated bag in order to decrease the risk of microorganism transmission and to prevent contamination of equipment. Item #3: Clinicians must maintain bags at all times in accordance with [Agency] Home Care's Infection Control Standards and must clean inside bags using low-level disinfectant and/or 70-90% isopropyl alcohol as necessary. Worn bags should be replaced as necessary. Item# 6, Bag Technique Procedure for professional clinicians" states: a. Establish a clean surface or place a protective shield (i.e., plastic liner) on the area bag is to be placed. b. Prepare a receptacle (plastic bag) for discarded contaminated items. h. Establish a clean surface. j. Place equipment to be used on a clean surface. k. Close the bag and perform tasks/procedures. l. Wash hands after completion of the task procedure. m. Clean used equipment when soiled following Infection Control Policy, q. Individualized equipment(s) must be cleansed according to Prevention of Transmission of Bloodborne/Body Fluid Pathogens." In 1 of 5 (20%) home visit observations, hand decontamination was not performed in accordance with CDC guidelines and agency policy. Home Visit 3: During the home visit on 2/14/2023, it was observed that the chaplain did not utilize a bag for equipment brought into the patient's home for the visit. It was not observed if the items were sanitized prior to entering the home. The items brought in were not sanitized before they were utilized while in the home at the beginning of the visit. The items included an iPad, bible, and elements for the sacrament (wafer and juice). All items were placed directly on the patient's end-table on the chair before moving other items on the table to accommodate them. A barrier was not utilized nor was the area sanitized or cleaned before the visit items were placed on the table. The chaplain did re-sanitize hands prior to beginning the visit at the patient's side. When ready to serve communion, the chaplain did not sanitize his hands before preparing/blessing the elements (opening and breaking of the wafer) and the chaplain needed to assist the patient in utilizing the individualized cup and wafer, making direct contact with the patient's hands. Once the sacrament was completed the packaging of the elements was placed back directly on the end-table. The chaplain did not re-sanitize hands after completing the sacrament and gathering the supplies (iPad, bible and phone) and carrying them to the front door. The chaplain did sanitize upon leaving the home but it was not witnessed whether or not the items were sanitized before placement in the car. On discussion after the visit, with the Administrator (Staff #1) and Assistant Director of Quality Management who attended the visit, it was confirmed that both individuals observed a breach in the infection control process as defined by the policy.

It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient's plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by a review of clinical records and interview. In 2 of 20 (10%) records reviewed, the agency’s Skilled Nurse (SN) failed to respond to the changes identified in the updated assessments with respect to standards of practice. The observation was made that documentation of patient information related to an individual who resides at home, directly pertaining to the evaluation of findings, was not present in the record. Clinical Record 4: The patient, who resides at home, was admitted to hospice on 7/29/2021 with the following diagnoses: Heart Disease, a History of MI, and Rheumatoid Arthritis. The Skilled Nursing (SN) visit note, dated 1/11/2022 for the purposes of recertification, documented the patient's personal goal for pain is “No pain”, rated at a 0, on a scale of 0-10 (worst pain possible). The assessment documented the patient’s ”pain in the shoulders, and chest as aching and moderate.” • The SN visit, on 1/27/2023, documented that current pain was rated as a 5/10 with previous pain at a 10/10 in the chest. Also, the SN visit note documented that the "patient had blacked out on the floor, maybe scooted from the chair but was found with an employee (privately hired) when the hospice nurse arrived. Pain medication was administered, (Roxanol 0.25ml sublingual). • The SN visit note, dated 2/1/2023, documented, ”Chest pain, aching, and dull pressure, rating worst pain at 10/10.” • On 2/3/2023, the SN visit note documented the patient’s pain rating as “moderate” (no numbers on a 1 to 10 scale). • On a subsequent visit, dated 2/6/2023, the SN documented the pain was “severe”. • The SN visit note dated 2/8/2023, documented ”No pain”, but the worst pain the client rated prior to this documented visit was the worst pain at 8/10. There is no documented evidence that the physician was notified of the pain experienced by this client to ensure the continuity of services in meeting the client’s goals for comfort, or that the caregivers were taught to communicate with the hospice professionals to ensure meeting the client’s goals for pain management. Clinical Record 13: The patient was admitted to hospice on 12/8/2022. The initial certification period, 12/8/2022 through 3/7/2023, included the diagnoses of CHF (congestive heart failure), HTN (hypertension, high blood pressure), and CAD (coronary artery disease). The patient was on Oxygen at 3 L per NC (liters via nasal cannula) and had a condom catheter to bedside drainage. The SN visit on 12/9/2022 documented a “Leaky condom catheter”. During the visit, the patient’s wife indicated that the patient had not had a BM (bowel movement) in 2 weeks. The RN documented that was Lactulose in the home and told the patient to restart the Lactulose once a day. On 12/10/2022, the wife calls again about condom catheter issues and agreed to the insertion of a foley catheter for the patient. The Gastrointestinal section of the Nurse Assessment document penned during the visit was left blank, thus if a gastrointestinal assessment had been completed could not be validated. On 12/12/2022, the LMSW (licensed medical social worker) made a visit and documented that the patient is eating better but still has “constipation issues.” The SN visit note, on 12/13/2022, documented, “last BM 11/29/2022, with abdomen distended, and tinkling bowel sounds”. Finally, on 12/15/2022 (7 days after patient admission on 12/8/2022), the RN narrative note, documented “Abdomen distended, no BM since admission, has been taking Lactulose once a day but has not been taking Senna.” The RN documented “Lactulose 10 g/15 ml, 30 cc 3 times a day, and Senna two times a day, 50 mg 8.6 oral tablets, 1 tab 2 times a day.” The clinical record evidenced that the patient had BMs on 12/18/2022. The RN had made a visit to perform wound care due to “feces on the dressing” and educated the spouse about catheter care. There was no documented evidence of a BM days after the admission, and ”20 days” according to the wife, from the time of admission. Nor was there documented “attention” to the patient’s gastrointestinal status for a significant number of days. During the exit interview on 2/16/2023, with the Administrator (Staff #1) it was stated that the agency will provide teaching to the hired caregivers, family, and employees in the home to ensure that they address the needs of the patients.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 12 (17%) records reviewed of patients provided with aide services, it was revealed that the agency did not ensure that the written care instructions for the hospice aide provided specific information directing the aide to perform tasks within the aide's scope of practice. Clinical Record 2: This is an 82-year-old male with a diagnosis of Dementia, and Diabetes, with the administration of Oral Hypoglycemics, and being monitored for blood glucose, residing in a long-term care facility. For the recertification episode dated 1/26/2023 through 4/25/2023, the Aide Care Plan assigned the Aide to “Shave every visit." The Aide assignment was not clear as to what type of razor to use for shaving this diabetic client. Clinical Record 13: The client is a male 76-year-old with diagnoses including CHF (congestive heart failure), HTN (hypertension), CAD (coronary artery disease), and Oxygen at 3 L per NC (liters per nasal cannula). It was documented upon admission that the client had a condom catheter in place. For the start of care episode 12/8/2023 through 3/7/2023, the Aide Care Plan dated 12/8/2023 assigned ”Catheter Care and Perineal Care.” On-call documented placement of a foley catheter, 16 French 10 cc Balloon, to bedside drainage, replacing the condom catheter, on 12/09/2022. The 16 French catheter was documented as having been replaced with an 18 French 10 cc Balloon catheter on 12/10/2022. There was an order to change this catheter every 30 days on 1/10/2023. There was no documented guidance on the Aide Care Plan, developed by the RN, to include instructions to the Aide related to the condom catheter being discontinued and replaced with an Indwelling Catheter. The Aide Care Plan needed updated instructions regarding cleansing around the urinary opening daily with soap and water, starting at the urinary opening and wiping down towards the drainage bag with soap and water. In an interview with the Administrator (Staff #1), on 2/15/2023, it was stated that the RN should provide specific instructions on the Aide Care Plan.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. This standard was not met as evidenced by a review of clinical records and interview. In 1 of 12 (8%) records of patients who had accepted Aide services, it was revealed that the Aide had not reported the refusal of services by the client to the Registered Nurse Case Manager, regarding the care ordered. Clinical Record 4: For the 14th recertification episode dated 1/20/2023 through 3/20/2023 the client's diagnoses included “Heart Disease, a History of MI,” and “Rheumatic Arthritis.” The Aide Plan of Care assigned the Aide to " Aide Shave Every Day with Razor." The patient refused to be shaved on 1/20/2023, 1/23/2023, 1/25/2023, 1/27/2023, 1/30/2023, 2/1/2023, 2/3/2023, 2/6/2023, and 2/8/2023. There was no documented communication note to the Registered Nurse Case Manager regarding the refusal of services during the daily care of twice a week. In an interview with the Administrator (Staff #1), on 2/15/2023, it was stated that the Aide should report refusal of care/changes to the plan of care to the Registered Nurse Case Manager.