Every finding on record at Vitas Healthcare of Texas, L.P.

Based on record review and interview, the agency failed to protect the rights of the patient by failing to manage the pain and symptoms related to the terminal illness and related conditions, in that Tramadol (used to treat pain) ordered three times a day, for a patient that lived at an assisted living facility memory care, was not managing the patient's pain as ordered for 1 (#1) of 7 patient records reviewed. The failure placed the patients at risk for uncontrolled pain and other symptoms, which could result in decreased in mobility. --- Patient #1:Record review of Patient #1's clinical record revealed an Initial Plan of Care dated 12/16/2024. The Plan of Care listed Cerebral Vascular Disease (group of conditions affecting blood flow and blood vessels in the brain) as the terminal diagnosis. The Plan of Care listed Vascular Dementia Severe (condition caused by the lack of blood that carrying oxygen and nutrients to the brain causing problems with reasoning, planning, judgment, and memory) as a diagnosis. The Plan of Care listed Hydrocodone/Acetaminophen (used to treat pain) 5-325 milligrams, 1 to 2 tablets, every 4 hours as needed (effective 12/16/2024, related to terminal condition), and Tylenol (used to treat pain or fever) 325 milligrams, 2 tablets every 8 hours as needed (effective 12/16/20204 related to the terminal condition), as medications. Registered Nurse A conducted an Initial Comprehensive Assessment on 12/17/2024. Registered Nurse A identified pain as an active problem for Patient #1. Facility Medication Technician 1 from Facility X called the agency on 1/6/2025 at 7:08 a.m. to report that Patient #1 had a fall, was found on the floor. Facility Medication Technician 1 reported that Patient #1 had a small bruise and scratch on the right hip.   Licensed Vocational Nurse B conducted a skilled nurse visit on 1/6/2025. Licensed Vocational Nurse B documented that the visit was an unscheduled visit due to a fall that morning. Licensed Vocational Nurse B documented that Patient #1 had a small bruise to the inner left hip and that there were no signs/symptoms of pain or discomfort noted.  Facility Medication Technician 2 called the agency on 1/6/2025 at 11:34 p.m. that Patient #1 had a fall, was in pain, and was given Tylenol. Registered Nurse C conducted a skilled nurse visit on 1/7/2025. Registered Nurse C documented that the purpose of the visit was due to a report from facility staff that Patient #1 slipped off the bed when getting up. Registered Nurse C's documentation did not address whether Patient #1 had pain.  Registered Nurse D conducted a skilled nurse visit on 1/15/2025. Registered Nurse D documented that Patient #1's pain level was scaled at 3. Registered Nurse D documented that the patient care giver called requesting an x-ray (also known as a radiograph- where a form of radiation creates pictures of the inside of the body). Patient #1 was complaining of pain. Registered Nurse D documented that x-rays and Tramadol (used to treat pain) 50 milligrams scheduled, three times each day were ordered. Patient #1's medication profile listed Tramadol 50 milligrams three times a day (related to terminal condition). An x-ray report indicated that an x-ray of the left hip was obtained on 1/15/2025. The x-ray results did not indicate a facture or dislocation of the left hip. Patient #1's record contained a medication list that listed Tramadol (used to treat pain) 50 milligram tablets, 1 tablet three times a day, was ordered on 1/15/2025 (Wednesday). Registered Nurse D conducted a skilled nurse visit on 1/16/2025. Registered Nurse D documented that Patient #1 had two falls, 1/6/ no year. Registered Nurse D documented that Patient #1 did not have pain based on non-verbal scoring. Facility Licensed Vocational Nurse called the agency on 1/18/2025 at 3:32 p.m. to report that Patient #1 had a fall. Registered Nurse E Conducted a skilled nurse visit on 1/19/2025. Registered Nurse E documented that Patient #1 had a witnessed fall by Patient #1 Family Member. Registered Nurse E documented that Patient #1 did not have pain. Registered Nurse E documented that Patient #1 was given Patient #1's morning medication from facility staff.  Patient #1 was taken to a minor emergency facility on 1/21/2025 by Patient #1 Family Member due to pain.  Patient #1 Family Member revoked hospice services on 1/22/2025. Patient #1's clinical record did not contain evidence that Tramadol frequency of administration had been changed to be administered earlier in the mornings for the pain Patient #1 was experiencing that interfered with the ability to get up out of bed, get dressed, and ambulate to the dining room for breakfast.Patient #1's clinical record did not contain evidence that a change in the frequency of Tramadol Administration had occurred. The clinical record did not indicate that Tramadol or other pain medication had been ordered to be given earlier in the morning to manage Patient #1's pain. Registered Nurse C and Registered Nurse D were not available for interview.  During an interview on 2/26/2025 at 3:22 p.m. with the Supervising Nurse/Alternate (been in the role for 90 days) and National Patient Care Administrator, the surveyor discussed Patient #1. Patient #1 had numerous falls; Tramadol was ordered three times a day on 1/15/2025; that a request had been made by Patient #1 Family Member for Patient #1 to receive a dose of Tramadol earlier in the morning because Patient #1 was having pain early in the morning that interfered with Patient #1's mobility. Patient #1 was unable to get out of bed, get dressed, and walk to the dining room for breakfast due to pain. The clinical record did not indicate that the Tramadol administration was changed for Patient #1 to receive a dose of Tramadol earlier in the morning. The clinical record did not indicate that another pain medication had been schedule for earlier in the morning. The surveyor asked what the facility's schedule for medication to be administered three times a day was. The Supervising Nurse/Alternate Administrator and National Patient Care Administrator did not know the frequency. The surveyor asked who would be responsible for getting medication administration time changed to earlier in the morning. The Supervising Nurse/Alternate Administrator informed the surveyor that the hospice would collaborate with the facility to have it provided at an earlier time. The surveyor asked where in the record it would indicate that the collaboration with the facility occurred. The Supervising Nurse/Alternate Administrator reviewed Patient #1's record and stated, "It doesn't (show collaboration)." The surveyor asked what the agency's policy on communication with patients and families via texted communication was. The Supervising Nurse/Alternate Administrator stated, "We do not permit them to text." During the record review, Team Manager F joined the review. Team Manager F had the same first name as Vitas Staff Member. The surveyor asked Team Manager F if Team Manager F had received calls or texts messages from Patient #1 Family Member regarding Patient #1's pain. Team Manager F stated, "I don't recall. I will check." Team Manager F reviewed Team Manager F's phone and informed the surveyor that Team Manager F was the manager on call on 1/6/2025 and Patient #1 had a fall on the floor and a small bruise on right hip. Team Manager F informed the surveyor that an Admit email was received on 12/18/2024 regarding requests for supplies, information of admit.  During an interview on 2/27/2025 at 12:31 p.m. with Licensed Vocational Nurse B, the surveyor asked about the services Licensed Vocational Nurse B provided for Patient #1. Licensed Vocational Nurse B informed the surveyor that Licensed Vocational Nurse B provided symptom management. Licensed Vocational Nurse B informed the surveyor that Patient #1 Family Member sent a video of Patient #1 walking. Licensed Vocational Nurse B stated, "I am not sure why [Patient #1 Family Member] sent it now. I reached out to the primary nurse. I did refer [Patient #1 Family Member] to the main number." The surveyor asked who the primary nurse was. Licensed Vocational Nurse B informed the surveyor that Licensed Vocational Nurse B believed the primary nurse was Registered Nurse D. The surveyor asked what Registered Nurse D's response was. Licensed Vocational Nurse B stated, "I think I just sent him a text to let [Registered Nurse D] know."  During an interview on 2/27/2025 at 4:25 p.m. with the Administrator, the Supervising Nurse/Alternate Administrator, the Vice President of Operations, the National Patient Care Administrator, the Business Manager, and Registered Nurse O, the surveyor asked how this could affect the patients. The Supervising Nurse/Alternate Administrator informed the surveyor that it could have a negative effect.  During an interview on 2/28/2025 at 4:17 p.m. with Patient #1 Family Member, the surveyor asked if Patient #1 was able to request pain medication when Patient #1 was experiencing pain. Patient #1 Family Member stated, "[Patient #1] could not make needs known, could not request pain medications." The surveyor received an email from Facility X Executive Director on 2/28/2025 at 5:23 p.m. The email read; "On TID (three times a day) we administer (medication) at 8am, 2 pm and 8pm unless directed by physician otherwise." -Texted communications between Patient #1 Family Member and Vitas staff.  The texted communication to Registered Nurse D was not dated but had "Thursday 5:28 p.m." The texted communication read as follows: " The #1 right now is that [Patient #1] gets the Tramadol morning dose before they try to get [Patient #1] out of bed in the morning (typically 6a-8a). If you ordered it TID and they get [Patient #1] up (resisting because [Patient #1] is hurting) and make [Patient #1] walk all the way to the dining room in pain to get pain medication (like this morning)..." Texted communication, no date, Monday at 8:32 a.m. from Registered Nurse D to Patient #1 Family Member read in part; "Good morning, I work Monday through Friday. So, I cannot address these until I see these now. I have sent these messages to my leadership, and they will be sending a nurse out. Keep in mind, we are a supplement to the facility and not primary care takers. We had adjusted the pain meds and as soon as we notice it's not working, then we can make adjustments. My recommendation is [Patient #1] can have first meal in bed so that [Patient #1] can get pain meds in [Patient#1's] system..." Texted communication, no date, timed 6:15 (a.m. or p.m. not specified), from Patient #1 Family Member to Licensed Vocational Nurse B read in part; "...[Patient #1] was denying pain but kind of short stepping with that right leg (indicating there's soreness somewhere, probably left 'SI' area). I saw them medicate [Patient #1] for pain last night..." Texted communication, no date, timed 6:15 (a.m. or p.m. not specified), from Patient #1 Family Member to Licensed Vocational Nurse B read in part; "I'm going to send you a video clip of [Patient #1] walking after [Patient #1] complained of left posterior hip/upper buttock pain this morning....Short stepping on the right, indicating pain on the left...I think it's coming from the SI joint (or L5-S1 nerve root)...[Patient #1] was denying pain but [Patient #1] ability to verbalize anything varies and even less often can [Patient #1] point out where it hurts. This morning was an occasion where [Patient #1] was able to do both..." Texted communication with Vitas Staff Member, undated read as follows: "As you can clearly see that message has a screen shot about uncontrolled pain that I sent to [Licensed Vocational Nurse B]. [Registered Nurse D] made no effort to address the issue. Originally, I asked for 1 scheduled dose of pain medication before 6:00 a.m. Instead, Tramadol t.i.d. (three times a day) was ordered and I immediately made it clear that foreseeably the Tramadol order (which took days) would not address the problem. Saturday I saw a 0800 video of [Patient #1] saying [Patient #1] hurt so bad [Patient #1] couldn't get up and [Patient #1] was crying out for help...I went to the facility and it was almost 10:00 before they (facility staff) took pain medication to the room for [Patient #1] and 11:00 before [Patient #1] was able to walk to the dining room and eat breakfast. Later that afternoon [Patient #1] fell again. What has [Hospice Agency] done to address the problem? Nothing. Apparently, it is just fine with [Hospice Agency] if my [Patient #1] suffers for hours and tears literally running down [Patient #1] face, no pain medicine, no food or drink. Even now Monday what has [Hospice Agency] done to address the issue? Nothing more than say they are going to 'check' on [Patient #1]..." Video The surveyor reviewed a video provided by Patient #1 Family Member. In the video, Patient #1 was wearing the same outfit that Patient #1 was wearing in a screen shot (provided by Patient #1 Family Member) of the video sent to Licensed Vocational Nurse B. The video was time-stamped 1/13/2025 at 8:02 a.m. The video shows a facility staff member asking if Patient #1's back hurt and telling Patient #1 that the staff member would ask the nurse to give the patient some medicine for back pain. The surveyor reviewed a video provided by Patient #1 Family member that was timed stamped 1/18/2025 at 9:11 a.m. The video showed a conversation with a facility staff and Patient #1 Family Member regarding Patient #1's pain. The video showed the facility staff member administering medication to Patient #1. The conversation between the facility staff member and Patient #1 Family Member referenced Tramadol was being given to Patient #1. Review of the agency's policy titled "418.52 Condition of Participation: Patient Rights." The policy was not dated. The policy read in part; "The patient has the right to be informed of his or her rights, and the hospice must protect and promote the exercise of these rights...(c). Standard: Rights of the patient. The patient has a right to the following: (1) Receive effective pain management and symptom control from the hospice for conditions related to the terminal illness..."

Based on record review and interview, the hospice failed to include in the plan of care all services, necessary drugs, and treatments for the palliation of the terminal diagnosis and related conditions in that wound care treatments were not included in the Plans of Care for 2 (#2, #5) of 2 patient records reviewed where hospice staff were performing wound care. The failure placed the patients at risk for wound infections and worsening of the wounds. --- Patient #2:Record review of Patient #2's clinical record revealed an Initial Plan of Care dated 11/11/2024. The Plan of Care listed Renal Cell Carcinoma (kidney cancer) as the terminal diagnosis.  Registered Nurse P conducted an Initial Comprehensive Assessment on 11/12/2024 and did not indicate that Patient #2 had wounds.  Licensed Vocational Nurse B conducted a skilled nurse visit on 11/12/2024. Licensed Vocational B documented that it was an unscheduled visit to drop off supplies. Licensed Vocational Nurse B documented on a "Supplemental Interdisciplinary Note," dated 11/13/2024 that supplies were dropped off to the home for a visit today. Registered Nurse A conducted a skilled nurse visit on 11/13/2024. Registered Nurse A documented that Patient #2 had a skin tear to the left forearm that measured 1.1 centimeters and a skin tear to the right forearm that measured 1 centimeter. Registered Nurse A did not document that wound care was provided.  Registered Nurse Q conducted a skilled visit on 11/15/2024. Registered Nurse Q documented that the skin tears to both arms were cleaned, and a dressing was placed over them.  Patient #2's Plan of Care did not include wound care treatment to the skin tears on Patient #2's forearms.  Patient #5:Record review of Patient #5's clinical record revealed an Initial Plan of Care dated 8/27/2024. The Plan of Care listed Rectal Cancer as the terminal diagnosis. Registered Nurse R conducted an Initial Comprehensive Assessment on 8/28/2024. Registered Nurse R did not identify that Patient #5 had wounds.  Licensed Vocational Nurse S conducted a skilled nurse visit on 8/29/2024. Licensed Vocational Nurse S documented that Patient #5 had a skin tear to the mid dorsal forearm (did not specify if left or right forearm) that measured 2 centimeters by 1.75 centimeters. Licensed Vocational Nurse S documented cleaning the wound with wound cleanser and covering the wound with a dressing and self-adhesive wrap.  Registered Nurse T conducted a skilled nurse visit on 10/3/2024. Registered Nurse T documented that Patient #5 had a skin tear to the left knee that measured 5 centimeters by 2 centimeters. Registered Nurse T documented cleaning the wound and applying a dressing.   Patient #5's Plan of Care did not include wound care treatment to the skin tears on Patient #5's forearm and knee. During an interview on 2/26/2025 at 3:22 p.m. with the Supervising Nurse/Alternate Administrator and the National Patient Care Administrator, the surveyor discussed that wound care treatments were performed to skin tears on Patient #2 and Patient #5, but wound care treatments were not included in the Plans of Care. The Supervising Nurse/Alternate Administrator reviewed the records. The Supervising Nurse/Alternate Administrator stated, "I don't see the orders for wound care." During an interview on 2/27/2025 at 9:35 a.m. with Licensed Vocational Nurse L, the surveyor discussed Patient #2. The surveyor asked if Patient #2 had wounds. Licensed Vocational Nurse L stated, "Not that I recall." During an interview on 2/27/2025 at 10:07 a.m. with Registered Nurse A the surveyor discussed Patient #2. The surveyor asked if Patient #2 had wounds. Registered Nurse A stated, "No, I don't recall. I'm sorry, I don't remember this patient." During an interview on 2/27/2025 at 10:41 a.m. with Registered Nurse R the surveyor asked what the process was when a patient had a new wound. Registered Nurse R stated, "I assess, take measurements, get orders from the physician, write the order on a physician order form." The surveyor asked what the agency's direction was on the timeframe for writing physician orders. Registered Nurse R stated, "I believe it is within 24 hours." During an interview on 2/27/2025 at 11:46 a.m. with Registered Nurse Q the surveyor discussed that Registered Nurse Q documented performing wound care on Patient #2. The Plan of Care did not include wound care treatment, how did you know what wound care to provide. Registered Nurse Q informed the surveyor that the nurse that went prior told Registered Nurse Q. The surveyor asked what nurse told you what the wound care was for Patient #2. Registered Nurse Q stated, "[Registered Nurse A] told me." During an interview on 2/27/2025 at 12:31 p.m. with Licensed Vocational Nurse B, the surveyor discussed Patient #2. The surveyor discussed Licensed Vocational Nurse B's documentation about taking supplies to Patient #2's home. Licensed Vocational Nurse B stated, "I don't remember. I know there were some nurses that were there, I just dropped some (supplies) off that were in my car. I don't believe I provided wound care." The surveyor asked what the agency's policy regarding documenting physician orders was. Licensed Vocational Nurse B stated, "Immediately, as soon as possible." During an interview on 2/27/20205 at 2:16 p.m. with Licensed Vocational Nurse S, the surveyor discussed Patient #5 and the wound care provided by Licensed Vocational Nurse S. Licensed Vocational Nurse S stated, "I don't remember honestly." The surveyor asked what the agency's policy regarding writing physician orders was. Licensed Vocational Nurse S stated, "I call the registered nurse on call; I tell them I want to call the Doctor; then I call the Doctor; I send an email to team nurse. The surveyor asked Licensed Vocational Nurse S if Licensed Vocational Nurse S would write the order. Licensed Vocational Nurse S stated, "Yes, I would." During an interview on 2/27/2025 at 2:26 p.m. with Registered Nurse T, the surveyor discussed Patient #5. The surveyor asked whether Patient #5 had any skin tears. Registered Nurse T stated, “No.” The surveyor asked what the agency’s policy about documentation of physician orders was. Registered Nurse T stated, “We write the order, you should have it as soon as possible. Repeat it to the physician and we have to upload and let the physician know so he can sign the orders.” During an interview on 2/27/2025 at 4:25 p.m. with the Administrator, the Supervising Nurse/Alternate Administrator, the Vice President of Operations, the National Patient Care Administrator, the Business Manager, and Registered Nurse O, the surveyor asked how this could affect the patients. The Supervising Nurse/Alternate Administrator informed the surveyor that it could have a negative effect. The Supervising Nurse/Alternate Administrator informed the surveyor that staff would not know what to do. Review of the agency's policy titled "VS Care Planning," not dated, read in part; Purpose 418.56 Condition of participation: Interdisciplinary group, care planning, and coordination of services....a...1. Standard: Plan of Care. All hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (is any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire...Standard: Content of plan of care...d). Drugs and treatment necessary to meet the needs of the patient..."

Based on record review and interview, the hospice failed to develop and maintain a system of communication and integration, in accordance with its policies and procedures, to provide and ensure the ongoing sharing of information between all disciplines providing care and services, in all settings, in that visits or phone calls to follow up with patients that had increased pain were not done for 2 (#4, #6) of 2 patient clinical records reviewed where follow up due to patient pain was requested. The failure placed the clients at risk that pain would not be controlled. --- Review of the agency's policy titled "VS Supervision, Delegation and Coordination," that was dated 5/16/2026 read in part: "Condition of participation: Interdisciplinary group, care planning, and coordination of services. The hospice must designate an interdisciplinary group or groups as specified in paragraph (a) of this section which, in consultation with the patient's attending physician, must prepare a written plan of care for each patient. The plan of care must specify the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such need relate to the terminal illness and related conditions. (a) Standard: Approach to service delivery. (1) The hospice must designate an interdisciplinary group or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. Interdisciplinary group members must provide the care and services offered by the hospice, and the group, in its entirety, must supervise the care and services. The hospice must designate a registered nurse that is a member of the interdisciplinary group to provide coordination of care and to ensure continuous assessment of each patient's and family's needs..." Patient #4:Record review of Patient #4's clinical record revealed an Initial Plan of Care dated 1/16/2025. The Plan of Care listed Esophageal (muscular tube that conveys food from the mouth to the stomach) Cancer as the terminal diagnosis. The Plan of Care listed Metastasis Neoplasm (spread of cancer) to the Lymph Nodes Lymph (small glands that filter lymphatic fluid and help fight infections) of the Head, Face, Neck, Metastasis Neoplasm of the Lung, and Neoplasm Metastasis to the Bone as other diagnoses. Review of the agency's telecare call documentation Patient #4 Family Member called on 1/18/2025 at 1:23 p.m. to report that Patient #4's pain was not controlled with Dilaudid (used to treat pain). Registered Nurse H documented that Patient #4 was agreeable for a focused virtual visit. Patient #4 reported generalized pain, scaled pain at 7 on a 0-10 pain scale. Patient #4 reported that pain was throbbing, constant, and Patient #4 was unable to sleep or lay on the right side.  Registered Nurse J called Physician I on 1/18/2025 at 2:41 p.m. about Patient #4's pain. Registered Nurse J documented that Physician I wanted Patient #4 to have an additional dose of Dilaudid 2 milligrams now and have triage call back in three hours to check on Patient #4. Registered Nurse J put in a note of notification that a follow-up phone call to Patient #4 was needed at 6:00 p.m.  Registered Nurse G documented on 1/18/2025 at 11:51 p.m. that a follow up call would be made in the morning due to time.  Registered Nurse K called Patient #4 on 1/19/2025 at 8:17 a.m. and spoke to Patient #4 Family Member. Registered Nurse K called to follow up with Patient #4, 16 hours after Physician I wanted triage to follow-up with Patient #4 regarding pain.   Patient #6:Record review of Patient #6's clinical record revealed an Initial Plan of Care dated 2/18/2024. The Plan of Care listed Colon Cancer as the terminal diagnosis. The Plan of Care listed Metastasis to the Lung, Metastasis to the Liver, and Metastasis to Lymph Nodes as other diagnoses.  Licensed Vocational Nurse L conducted a skilled nurse visit on 2/23/2024. Licensed Vocational Nurse L documented that Patient #6 reported a pain scale of 9, on a 0-10 pain scale. Patient #6 reported pain to the lower abdomen (belly) and lower back. Licensed Vocational Nurse L documented that the team will follow-up on Sunday (2/25/2024). Licensed Vocational Nurse L documented that triage was notified.  Review of Patient #6's clinical record did not contain evidence that the hospice followed up with Patient #6 regarding pain on Sunday 2/25/2024. Review of the agency's Telecare call documentation.  Licensed Vocational Nurse M documented on 2/25/2025 at 2:38 a.m. "Please have team visit patient on Sunday per [Physician N's] request." During an interview on 2/26/2025 at 3:22 p.m. with the Supervising Nurse/Alternate Administrator and the National Patient Care Administrator, the surveyor discussed that staff were instructed by the physicians to follow up with patients, and there was no evidence that the follow ups were done. The surveyor asked why triage did not call Patient #4 back on 1/18/2025 at 6:00 p.m. The Supervising Nurse/Alternate Administrator informed the surveyor that it was not transferred to the team until 11:51 p.m. The surveyor asked why the visit for Patient #6 for follow up on 2/25/2024 was not done. The National Patient Care Administrator went to check on it. The National Patient Care Administrator informed the surveyor that there was no visit for 2/25/2024. The Supervising Nurse/Alternate Administrator informed the surveyor that it was an issue with how the call was dispatched.  During an interview on 2/27/2025 at 4:25 p.m. with the Administrator, the Supervising Nurse/Alternate Administrator, the Vice President of Operations, the National Patient Care Administrator, the Business Manager, and Registered Nurse O, the surveyor asked how this could affect the patients. The Supervising Nurse/Alternate Administrator informed the surveyor that it could have a negative effect.

Based on record review and interview, the registered nurse failed to conduct annual on-site supervision visits, at a location where a patient was receiving care, to observe and assess the care performed by the aide, in 3 (Hospice Aide R, Hospice Aide S, and Hospice Aide T) of 3 hospice aide records reviewed. The failure placed the clients at risk of inappropriate personal care services. --- The surveyor started reviewing personnel records on 9/29/2023. The personnel records were missing required documents. A list of the missing documents were given to the Administrator on 9/29/2023. The list included the the last on-site evaluation by a registered nurse for Hospice Aides R, S, and T. Hospice Aide R: Record review of Hospice Aide R's personnel record indicated 9/26/2005 as the date of hire. Hospice Aide R's personnel record contained documentation of an annual onsite evaluation dated 6/10/2021. The personnel record contained a document titled "2022 - Clinical Competency Assessment - Aide" which was not dated. The document had a date range of 1/1/2022 to 12/31/2022. The document did not indicate the care provided by Hospice Aide R that was observed and assessed by a registered nurse. The document did not indicate that care was provided by Hospice Aide R on-site at a location where a patient would receive care. The surveyor was given a copy of 2 documents that were titled "Nursing-Updated Comprehensive Assessment." The surveyor was given page 6 of the 6 page documents. The documents were dated 8/22/2023 and 8/29/2023. The documents had an area to document supervision. The registered nurse could mark "indirect or direct (on site) supervision." The area was marked indirect on 8/22/2023 by Registered Nurse H. The supervision area was marked indirect on 8/29/2023 by Registered Nurse G. Hospice Aide R's personnel record did not contain evidence that a registered nurse made an annual onsite visit to observe and assess care provided by Hospice Aide R at a location where a patient received care after 6/10/2021. Hospice Aide S: Record review of Hospice Aide S's personnel record indicated 2/21/2000 as the date of hire. Hospice Aide S's personnel record contained documentation of an annual onsite evaluation dated 6/10/2021. The personnel record contained a document titled "2022- Clinical Competency Assessment - Aide" which was not dated. The document had a date range of 1/1/2022 to 12/31/2022. The document did not indicate the care provided by Hospice Aide S that was observed and assessed by a registered nurse. The document did not indicate that care was provided by Hospice Aide S on-site at a location where a patient would receive care. The surveyor was given a copy of 2 documents that were titled "Nursing-Updated Comprehensive Assessment." The surveyor was given page 6 of the 6 page documents. The documents were dated 7/3/2023 and 8/3/2023. The documents had an area to document supervision. The registered nurse could mark "indirect or direct (on site) supervision." The area was marked indirect on 7/3/2023 by Registered Nurse J. The supervision area was marked indirect on 8/3/2023 by Registered Nurse I. Hospice Aide S's personnel record did not contain evidence that a registered nurse made an annual onsite visit to observe and assess care provided by Hospice Aide S at a location where a patient received care after 6/10/2021. Hospice Aide T: Record review of Hospice Aide 's personnel record indicated 2/21/2000 as the date of hire. Hospice Aide S's personnel record contained documentation of an annual onsite evaluation dated 6/10/2021. The personnel record contained a document titled "2022- Clinical Competency Assessment - Aide" which was not dated. The document had a date range of 1/1/2022 to 12/31/2022. The document did not indicate the care provided by Hospice Aide T that was observed and assessed by a registered nurse. The document did not indicate that care was provided by Hospice Aide S on-site at a location where a patient would receive care. The surveyor was given a copy of 2 documents that were titled "Nursing-Updated Comprehensive Assessment." The surveyor was given page 6 of the 6 page documents. The documents were dated 6/23/2023 and 8/11/2023. The documents had an area to document supervision. The registered nurse could mark "indirect or direct (on site) supervision." The area was marked indirect on 6/23/2023 by Registered Nurse K. The supervision area was marked indirect on 8/11/2023 by Registered Nurse L. Hospice Aide T's personnel record did not contain evidence that a registered nurse made an annual onsite visit to observe and assess care provided by Hospice Aide T at a location where a patient received care after 6/10/2021. During an interview on 10/2/2023 with the Alternate Administrator/Director of Nursing, the surveyor discussed that the documents titled "2022- Clinical Competency Assessment - Aide" and "Nursing-Updated Comprehensive Assessment." The 2022 - Clinical Competency Assessment - Aide documents were not dated and did not indicate that a registered nurse conducted a visit onsite to observe and assess the aide. The Nursing-Updated Comprehensive Assessment were marked as indirect supervision, not as direct (on-site) supervision. The Alternate Administrator/Director of Nursing stated, "Oh, they're not." The agency was not able to give the surveyor documentation of onsite supervision of the hospice aides by a registered nurse for 2022.

Based on record review and interview, the agency failed to include physician orders in the clinical record for 2 (#1,#2) of 2 patient records reviewed where the nurses performed wound care and for 1 (#19) of 2 patient records reviewed where the patient received respite services. The failure placed clients at risk of the omission or care of inappropriate care which could result in a negative outcome. --- Patient #1: Record review of Patient #1's record revealed an Initial Plan of Care dated 6/14/2023. The Plan of Care listed Cerebral Atherosclerosis (thickening or hardening of the arteries) as the primary diagnosis. Licensed Vocational Nurse D conducted a skilled nurse visit on 7/17/2023. Licensed Vocational Nurse D documented that that Patient #1 had a skin tear to the left mid dorsal forearm that measured 8 centimeters by 7 centimeters. Licensed Vocational Nurse D documented that the wound was cleansed with sterile water and was covered with a non-stick bandage followed by a large-bordered gauze. Patient #1's record did not contain an physician order for wound care. During a telephone interview on 9/30/2023 at 4:05 pm with Licensed Vocational Nurse D, the surveyor discussed Patient #1 wound and the wound care provided. Licensed Vocational Nurse informed the surveyor that an order was received from the physician but "forgot to write the order." Patient #2: Record review of Patient #2's record revealed an Initial Plan of Care dated 4/21/2023. The Plan of Care listed Non-Traumatic Subdural Hemorrhage (a bleed within the skull but outside of brain tissue) as the primary diagnosis. Registered Nurse E conducted a skilled nurse visit on 5/15/2023. Registered Nurse E documented that Patient #2 had an abrasion to the left lateral thigh that measured 4 centimeters and that a bandage was removed and recovered with a clean bandage. Patient #2's record did not contain an order for wound care. Registered Nurse E was no longer employed by the agency. During record review on 9/27/2023 at 2:26 pm with the Director of Nursing, the surveyor discussed that wound care was performed on 5/15/2023 but the record did not contain an order for wound care. The Director of Nursing would review the record. During an interview on 9/29/2023 at 10:56 a.m. with the Director of Nursing, the Director of Nursing stated, "I did not find an order for wound care earlier than 9/5/2023, no order for 5/15/2023." Patient #19: Record review of Patient #19's record revealed a Plan of Care Review that was dated 6/22/2023. The Plan of Care Review listed Alzheimer's Disease (dementia that affects memory, thinking and behavior) as the primary diagnosis. Social Worker F documented on an agency document titled "Supplemental Interdisciplinary Note" that was dated 7/26/2023 Social Worker F documented that a phone call was made to Patient #19's caregiver to follow-up with respite needs. Patient #19's caregiver agreed for Social Worker F to start respite referral with the respite days to be 8/2/2023 to 8/7/2023. Social Worker F documented on 8/2/2023 that respite was scheduled for 8/3/2023 to 8/8/2023. Registered Nurse G conducted a skilled nurse visit on 8/3/2023 and documented that Patient #19 was adjusting well to respite stay. Social Worker F conducted a visit on 8/4/2023 and documented that Patient #19 was currently on respite. Licensed Vocational Nurse D conducted skilled nurse visit on 8/5/2023 and 8/6/2023 and documented the visits as respite visits. Social Worker F conducted a visit on 8/7/2023 and documented that Patient #19 was currently on respite. Patient #19's Patient record did not contain an order for respite care. During record review on 9/27/2023 at 2:26 p.m. with the Director of Nursing, the surveyor discussed that Patient #19 was on respite care but there was no order for respite care. The Director of Nursing would review the record. During an interview on 9/29/2023 at 10:56 with the Alternate Administrator/Director of Nursing, the Alternate Administrator/Director of Nursing did not have the order for respite care. The Alternate Administrator/Director of Nursing brought a stack of documents for multiple patients. The Director of Nursing informed the surveyor that if it wasn't in the documents provided, "we didn't have it." The agency had a policy titled "Interdisciplinary Team Policies Clinical Record" that was labeled 5:20 with a revision date of 11/8/2019. The policy read in part: "Policy Confidential and detailed clinical records providing documentation of hospice services rendered by all members of the interdisciplinary team will be maintained for each patient/family taken under care. The clinical record shall be accurate in all respects, and shall not misrepresent the patient's condition in order to justify reimbursement. Objective To maintain confidential, accurate and detailed clinical records accurately reflecting the care provided to each patient/family. Procedure 1. The clinical record includes but is not limited to the following:...h. Initial Plan of Care/Physician Orders..."