Every finding on record at Wesley Community Services, Inc.

Based on clinical record review and hospice policy review, the hospice failed to ensure the hospice Interdisciplinary Group developed patient plans of care which specified the scope and frequency for all services required by and provided to patients for 3 of 19 sampled patients (Patients #1, #15 and #17). Failure to identify a scope and frequencies for all ordered services increased the potential for hospice services to not adequately meet the needs of hospice patients and families. --- 3.Patient #1 had a hospice admission date of 1/27/25 and received hospice services while residing in a private residence. Clinical record review revealed the following: a. The POC, dated 1/27/25 to 4/26/25, identified the patient had a diagnosis of Dementia due to Alzheimer's disease and IDG orders for skilled nursing twice weekly, hospice aide five times a week and chaplain service to evaluate. b. Chaplain visit note, dated 2/13/25, identified Chaplain will be visiting patient every other Wednesday. c. The IDG meeting note to update the POC, dated 2/5/25, lacked documentation to identify specific frequency and duration for chaplain services. The IDG failed to include a detailed scope and frequency of all services necessary to meet the patient/family needs. The above findings were reviewed with the Executive Director, Director of Clinical Quality and Staff C, Clinical Manager. Findings include: Review of the hospice policy, titled Plan of Care, dated 05/2024, identified the written plan of care will contain frequency/amount/duration of services. 1.Patient #15 had a hospice admission date of 3/11/24, a revocation date of 4/3/24, and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care (POC), dated 3/11/24 to 6/8/24, included primary diagnosis of heart failure and chronic kidney disease and Interdisciplinary Group (IDG) orders for skilled nursing, social work, chaplain, music therapy and hospice aide services. b. The IDG meeting note to update the POC, dated 3/13/24, included documentation massage therapy services was not applicable. c. The IDG meeting note to update the POC, dated 3/27/24, lacked documentation of IDG order for massage therapy. d. Massage therapy note, dated 3/29/24, identified massage therapy techniques were performed. e. Interim physician order, dated 4/12/24, included order for massage therapy services but lacked a visit frequency and duration. The IDG meeting notes to update the POC failed to identify specific frequency and duration for massage therapy services. 2. Patient #17 had a hospice admission date of 10/9/24, a death date of 11/27/24, and, and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 10/9/24 to 1/6/25, included primary diagnosis of senile degeneration of brain and IDG orders for skilled nursing twice a week, hospice aide 3 times a week, social work, chaplain, music therapy and massage therapy services to evaluate. b. The IDG meeting notes to update the POC, dated 10/16/24, 10/30/24, and 11/13/24, lacked documentation massage therapy services evaluation was completed or declined by patient and/or caregiver. The clinical record lacked massage therapy visit notes. The IDG meeting notes to update the POC failed to identify specific frequency and duration for massage therapy services or documentation the service had been declined.

Based on staff interview, clinical record review and hospice policy review, the hospice failed to ensure coordination and collaboration among Interdisciplinary Group members occurred to ensure updates to the plan of care and the services provided to the patients were according to assessed needs and wound measurements were documented weekly for 5 of 6 sampled patients with wounds (Patients #5, #7, #8, #12 and #13). Failure of the hospice team members to accurately update the plan of care and collaborate and communicate effectively increased the risk that patients did not receive services to meet assessed needs. --- 4. Patient #8 had a hospice admission date of 11/29/24 and received hospice services while residing in a private home. Clinical record review revealed: a. The POC, dated 11/29/24 to 2/26/25, included primary diagnosis of Emphysema and interim physician orders for skilled nursing services three times per week, chaplain and social work services. b.. Skilled nurse visit note, dated 11/30/24, Staff G, RN, included identification of a pressure ulcer on the left hip with measurements of length 1.9 cm by width 1.5 cm by depth 0 cm. c. Physician order dated 11/30/34, noted by Staff G, RN, for wound care to the left hip to include: cleanse the wound with cleanser of choice, pat dry, apply Mepilex dressing and change every 7 days or as needed if soiled or falls off. Follow up with treatment to monitor effectiveness or need to adjust. d. Skilled nurse visit note, dated 12/2/24, Staff G, RN, documented wound care completed, but lacked documentation of wound description and measurements. e. Skilled nurse visit note, dated 12/924, Staff R, LPN, documented wound care completed, but lacked documentation of wound description and measurements. f. Skilled nurse visit note, dated 12/16/24, Staff G, RN, documented wound care completed, but lacked documentation of wound description and measurements. g. Skilled nurse visit note, dated 12/24/24, Staff G, RN, documented wound care completed, but lacked documentation of wound description and measurements. h. Skilled nurse visit note, dated 12/30/24, Staff G, RN, documented wound care completed, but lacked documentation of wound description and measurements. i. Skilled nurse visit note, dated 1/13/25, Staff R, LPN, documented wound care completed, but lacked documentation of wound description and measurements. j. Skilled nurse visit note, dated 1/20/25, Staff R, LPN, documented wound care completed, but lacked documentation of wound description and measurements. k. Skilled nurse visit note, dated 1/27/25, Staff G, RN documented wound care completed, but lacked documentation of wound description and measurements. l. Skilled nurse visit note, dated 2/3/24, Staff G, RN, documented wound care completed, but lacked documentation of wound description and measurements. m. Skilled nurse visit note, dated 2/11/25, Staff R, LPN, documented wound care completed, but lacked documentation of wound description and measurements. n. Skilled nurse visit note, dated 2/17/25, Staff R, LPN, documented wound care completed, but lacked documentation of wound description and measurements. The hospice failed to assess the left hip wound and obtain weekly wound measurements. 5. Patient #12 had a start of care date of 2/7/25 and received hospice services in a private home. Clinical record review revealed the following: a. The POC, dated 2/7/25 to 5/7/25, included primary diagnosis of liver cancer and interim physician orders for skilled nursing services two times per week, chaplain and social work services. b. The skilled nurse visit note, dated 2/24/25, noted a new pressure ulcer documented as unstageable and measurements of length 1.75 cm by width 1.54 cm , but lacked a depth measurement. The hospice failed to assess and obtain weekly wound measurements including length by width by depth. Findings reviewed with the Administrator, Executive Director, Director of Clinical Quality and Staff C, Clinical Manager 3. Patient #5 had a hospice admission date of 1/3/25 and received services while residing in a nursing home. Clinical record review revealed the following: a. The POC, dated 1/3/25 to 4/2/25, identified the patient had a diagnosis of Dementia due to Alzheimer's disease and included Interdisciplinary Group (IDG) orders for skilled nurse, social worker, hospice aide and chaplain services. b. IDG meeting note to update the POC, dated 2/5/25, included interim physician orders for skilled nursing and hospice aide services twice a week. c. Skilled nurse visit note, dated 2/13/25, completed by Staff F, RN, included documentation of a wound to left ring finger. Documentation identified the wound to be covered and recently dressed measuring 1 cm by 2 cm with no tunneling. The skilled nurse failed to assess the wound and the wound measurement lacked a wound depth. The hospice failed to assess and obtain weekly wound measurements including length by width by depth. Findings include: According to the hospice policy, titled Skin Management, dated 02/2025, identified a comprehensive wound assessment will be completed at every admission visit to include measurements (length x width x depth). Wounds will be visualized at every visit and measured one time a week to include length x width x depth. A comprehensive wound assessment will be completed weekly and with every comprehensive assessment time point (admission, recertification, update to comprehensive assessment and live discharge). During an interview on 2/20/25 at 9:00 AM, Staff C, Clinical Manager, reported hospice expectation is wound assessment done weekly, measure length x width x depth. If patient resides in a nursing home, hospice staff schedule visits to visualize wounds and may take measurements from facility documentation. 1.Patient #7 had a hospice admission date of 8/23/24 and received hospice services while residing in a private home. Clinical record review revealed: a. The Plan of Care (POC), dated 8/23/24 to 11/21/24, included primary diagnosis of Parkinsons disease and interim physician orders for skilled nursing services, social work and hospice aide services. b. IDG meeting note to update the POC, dated 2/5/25, included interim physician orders for skilled nurse twice a week and hospice aide twice a week services. c. Skilled nurse visit note, dated 2/3/25, included documentation of a pressure ulcer (wound) to the intergluteal cleft (area between the buttocks), measured 0.3 centimeters (cm) by 0.2 cm. The wound measurements lacked a wound depth. d. Skilled nurse visit note, dated 2/10/25, included documentation no new skin lesions reported or observed. The note lacked wound measurements. e. RN (registered nurse) Update to Comprehensive Assessment, dated 2/14/25, included documentation no new skin lesions reported or observed. The note lacked wound measurements. The week of 2/2/25, the wound measurements lacked a depth and the week of 2/9/25, lacked wound measurements. The hospice failed to obtain weekly wound measurements. 2. Patient #13 had a hospice admission date of 12/24/24 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 12/24/24 to 3/23/25, included primary diagnosis of Chronic Kidney Disease and interim physician orders for skilled nursing, social work, chaplain, music therapy, massage therapy and hospice aide services. b. Start of Care comprehensive assessment note, dated 12/24/24, included documentation of left lower leg wound with drainage, abrasion to left ear, and right lower extremity with drainage, unable to assess wounds due to patient sleeping. c. Skilled nurse phone call note, dated 12/30/24, included documentation the caregiver called to discuss multiple topics, including patient wounds. d. Skilled nurse phone call note, dated 1/5/25, included documentation regarding update for caregiver. Bottom is pink but no open wounds, ear wound almost healed and patients legs have multiple small blisters and are weeping (fluid). e. RN Update to Comprehensive Assessment, dated 1/8/25, included documentation abdominal fold treated with nystatin but not healing and possible new butt wound, patient has current treatment for bottom. f. RN Update to Comprehensive Assessment, dated 1/13/25, included documentation nystatin was changed to miconazole (treatment for abdominal fold) and area on bottom being treated with calmoseptine. g. RN Update to Comprehensive Assessment, dated 1/21/25, included documentation red area on bottom being treated with calmoseptine. h. Skilled nurse phone call note, dated 2/2/25, included documentation patient has skin tear to right forearm and buttocks red and excoriated. i. Skilled nurse visit note, dated 2/10/25, included documentation right gluteal fold measured 4.5 cm x 5.5 cm but lacked a wound depth. j. Skilled nurse visit note, dated 2/14/25, included documentation left anterior forearm bleeding, measured 1 cm x 1 cm but lacked a wound depth. The hospice failed to obtain weekly wound measurements.

Based on staff interview, clinical record reviews and hospice policy reviews, the hospice failed to ensure the Interdisciplinary Group (IDG) maintained a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the Plan of Care for 6 of 19 sampled patients (Patients #1, #3, #11, #14, #17 and #19). Failure of the hospice IDG members to maintain a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care, increased the risk that patients did not receive services to meet assessed needs. Findings include: --- 6. Patient #17 had a hospice admission date of 10/9/24, a death date of 11/27/24, and, and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 10/9/24 to 1/6/25, included primary diagnosis of senile degeneration of brain and IDG orders for skilled nursing, hospice aide 3 times a week, social work, chaplain, music therapy and massage therapy services. b. The IDG meeting notes to update the POC, dated 10/16/24 and 10/30/24, included IDG direction to provide two hospice aide visits each week. c. Hospice aide visits were completed weekly, dated 10/28/24, 10/30/24 and 11/4/24. d. The week of 10/27/24 to 11/2/24 lacked documentation of a third completed hospice aide visit. e. The IDG meeting notes to update the POC, dated 10/30/24 and 11/13/24, lacked documentation the IDG was notified of the missed hospice aide visit for the week of 10/27/24. The hospice failed to provide hospice aide visits as ordered per the IDG meeting notes to update the POC. Findings reviewed with the Administrator, Executive Director, Director of Clinical Quality and Staff C, Clinical Manager. 5.Patient #9 had a hospice admission date of 8/30/24, a death date of 9/6/24, and received hospice services while residing in an acute hospital. Clinical record review revealed: a. The POC, dated 8/30/24 to 9/6/24, included primary diagnosis of senile degeneration of brain and IDG orders for skilled nursing daily, social work and chaplain services. b. Skilled Nurse visit notes were completed on 9/2/24, 9/3/24, 9/4/24, and 9/5/24. c. The clinical record lacked documentation of a skilled nurse visit on 9/1/24. d. The IDG meeting notes dated 9/11/24, lacked documentation the IDG was notified of the missed skilled nurse visit on 9/1/24. The hospice failed to skilled nurse visits as ordered per the POC. According to the agency policy, titled Missed Visits, revised 10/2020, missed visits will be communicated to the Interdisciplinary Group (IDG). If a visit is missed for any reason, the clinician should attempt to reschedule the visit for the same week so the physician ordered frequency is maintained. If the visit is not rescheduled, the clinician notifies the IDG and clinical supervisor of the missed visit and documents the clients name, date and type of visit missed, reason for missed visit, and description of any unmet needs. During an interview on 2/20/25 at 3:30 PM, the Hospice Medical Director stated missed visits are discussed at IDG. 1.Patient #1 had a hospice admission date of 1/27/25 and received hospice services while residing in a private residence. Clinical record review revealed the following: a. The Plan of Care (POC), dated 1/27/25 to 4/26/25, identified the patient had a diagnosis of Dementia due to Alzheimer's disease and included orders for skilled nurse, social worker, hospice aide five times a week and chaplain services. b. The week of 1/26/25 to 2/1/25, hospice aide completed visits 1/28/25, 1/29/25 and 1/30/25. c. The IDG meeting notes to update the POC, dated 2/5/25 lacked documentation the IDG was notified of the missed hospice aide visits for the week of 1/26/25. The hospice failed to provide hospice aide visits as ordered per the POC. 2. Patient #3 had a hospice admission date of 2/7/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 2/7/25 to 5/7/25, identified patient had a diagnosis of Chronic obstructive pulmonary disease and IDG orders for skilled nursing services and hospice aide services two times a week. b. The week of 2/2/25 to 2/8/25 lacked documentation of completed hospice aide visits. c. The IDG meeting notes to update the POC, dated 2/19/25, lacked documentation the IDG was notified of the missed hospice aide visits for the week of 2/7/25. The hospice failed to provide hospice aide visits as ordered per the IDG meeting notes to update the POC. 3. Patient #11 had a hospice admission date of 1/23/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 1/23/25 to 4/22/25, identified patient had a diagnosis of Intrahepatic bile duct carcinoma and IDG orders for skilled nurse visits two times weekly and hospice aide visits two times weekly. b. The IDG meeting notes to update the POC, dated 2/5/25, included IDG direction to provide two skilled nurse visits weekly and two hospice aide visits weekly. c. The weeks of 1/19/25 to 1/25/25 and 1/26/25 to 2/1/25 lacked documentation of a second skilled nurse visit. d. The week of 1/19/25 to 1/25/25 lacked documentation of any hospice aide visits. e. The IDG meeting notes to update the POC, dated 2/5/25, lacked documentation the IDG was notified of the missed skilled nurse visits the weeks of 1/19/25 and 1/26/25 and of the missed hospice aide visits the week of 1/19/25. The hospice failed to provide hospice aide visits as ordered per the IDG meeting notes to update the POC. 4. Patient #14 had a hospice admission date of 1/8/25 and received hospice services while residing in a nursing home. Clinical record review revealed the following: a. The POC, dated 1/8/25 to 4/7/25, identified the patient had a diagnosis of unspecified severe protein calorie malnutrition and included orders for skilled nursing, hospice aide visits two times weekly, social worker and chaplain services. b. The IDG meeting notes to update the POC, dated 1/22/25, included IDG direction to provide two hospice aide visits each week. c. The week of 1/5/25 to 1/11/25 lacked documentation of any hospice aide visits. d. The IDG meeting notes to update the POC, dated 1/22/25, lacked documentation the IDG was notified of the missed hospice aide visits for the week of 1/5/25. The hospice failed to provide hospice aide visits as ordered per the IDG meeting notes to update the POC.

Based on observations, staff and agency interviews, clinical record review and agency policy review, the hospice failed to develop and maintain a system of communication and integration in accordance with hospice's own policies and procedures as evidenced by failing to update the Plan of Care based on the patients assessments and needs for 3 of 19 sampled patients (Patients #6, #14 and #19). Failure to ensure hospice staff provide care and services in accordance with an updated Plan of Care developed by the interdisciplinary Group (IDG) placed the patient at risk for not receiving necessary care and services to meet the needs of the patient. --- 2. Patient #6 had a hospice admission date of 1/28/25 and received services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 1/28/25 to 3/28/25, identified the patient had a diagnosis of Alzheimer's disease with early onset and included orders for skilled nurse, social worker, hospice aide chaplain and music therapy services. b. Skilled nurse comprehensive assessment, dated 2/6/25, completed by Staff W, RN, identified staff at the nursing home have been utilizing a Hoyer lift to transfer the patient due to pain and stiffness. c. Hospice aide completed visits on 2/7/25 and 2/11/25 and hospice care plan continues to provide RN instruction for aide to transfer patient using EZ stand and assist of two. The RN failed to update the aide care plan based on assessment of the patient's needs. 3. Patient #14 had a hospice admission date of 1/8/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 1/8/25 to 4/7/25, identified the patient had a diagnosis of unspecified severe protein calorie malnutrition and included orders for skilled nursing, hospice aide, social worker and chaplain services. b. Chaplain visit note, dated 1/14/25, completed by Staff K, identified chaplain visits would increase to weekly. c. The IDG meeting notes to update the POC, dated 1/22/25 and 2/5/25 included orders for hospice chaplain services 2 times monthly. The IDG failed to update the patient's POC based on assessed needs. The above information was reviewed with the Administrator, Executive Director, Director of Clinical Quality and Staff C, Clinical Manager. Findings include: According to the agency policy titled The Plan of Care, dated 5/2022, a written Plan of Care will be established and maintained for each individual admitted to the hospice program. The care provided to the client must be in accordance with the plan of care. The Plan of Care will be based on the initial comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but not less than every 15 days. 1.Patient #18 had a start of care date of 9/20/24 and a death date of 10/26/24, with a primary diagnosis of end stage Parkinson's and received services in a long term care facility. a. The Plan of Care (POC), dated 8/30/24 to 11/27/24 and included physician orders for all services, medications and treatments. b. The skilled nurse service note, dated 9/30/24, Staff V, Registered Nurse (RN), included documentation that noted new onset of edema (fluid) in both legs that was weeping out. Documentation indicated the RN would contact the physician for orders to address the edema. c. Physician order, dated 9/30/24, noted by Staff V, RN, for the medication Lasix 40 milligrams (a medication that pulls fluid from the body) one tablet a day for three days was received. d. The skilled nurse service note, dated 10/11/24, indicated an order for wrapping the lower legs with gauze pads and kerlix wrap, however the clinical record lacks a specific treatment order for both of the lower legs. e. The skilled nurse service note, dated 10/15/24, Staff S, Licensed Practical Nurse (LPN), included documentation of both legs being wrapped by facility staff for weeping. f. The skilled nurse service note, dated 10/17/24, Staff V, RN, included documentation of facility staff wrapping both legs twice a day related to legs weeping fluid. g. The skilled nurse service note, dated 10/23/24, Staff S, LPN included documentation of patients lower legs being wrapped due to fluid weeping. The agency failed to obtain and update the POC with treatment orders for wrapping the patient's lower legs.

Based on clinical record review, review of employee personnel files, and hospice staff interview, the hospice failed to ensure 2 of 6 hospice aides (Staff J and Staff L) demonstrated competency in the performance of any skills which exceed the level of basic hospice aide skills in the presence of a registered nurse with competency determined at a patient's bedside or using a real person (pseudo-patient) prior to being assigned to perform the task independently for 2 of 11 sampled patients who required an extra skill to be performed (Patients #3 and #7). Failure to ensure hospice aides have a competent ability to perform all skills above and beyond basic hospice skills increased the risk for patients to receive inadequate or inappropriate care. Findings include: --- The Medicare Conditions of Participation direct that the hospice aide may not independently provide any patient cares beyond the basic required skills without successful instruction and demonstration of competency in extra skills assigned on the aide care plan. During an interview on 2/25/24 at 3:10 PM The Director of Clinical Quality stated the hospice had no further documentation of hospice aide competencies. 1. Patient #3 had a start of care date of 2/7/25, and received hospice services while residing in a nursing home. The aide care plan included Registered Nurse (RN) instructions to the aide to utilize the pivot disc for transfers. Review of the clinical record showed Staff J, Hospice Aide and Staff L, Hospice Aide, provided aide services independently for Patient #3. Staff J, Hospice Aide, had a hire date of 8/19/24. Staff Fs personnel file lacked documentation RN had observed Staff J competently perform the task utilizing a pivot disc transfer. Staff L, Hospice Aide, had a hire date of 7/16/18. Staff Ls personnel file lacked documentation RN had observed Staff L competently perform the task utilizing a pivot disc transfer. 2. Patient #7 had a start of care date of 8/23/24, and received hospice services while residing in a private residence. The aide care plan included RN instructions to the aide to utilize the pivot disc for transfers, provide nectar thick liquids for intake and range of motion. Review of the clinical record showed Staff J and Staff L, Hospice Aide, provided aide services independently for Patient #3. Staff J, Hospice Aide, had a hire date of 8/19/24. Staff Js personnel file lacked documentation RN had observed Staff J competently perform the task utilizing a pivot disc transfer, nectar thick liquids and range of motion. Staff L, Hospice Aide, had a hire date of 7/16/18. Staff Ls personnel file lacked documentation RN had observed Staff L competently perform the task utilizing a pivot disc transfer and nectar thick liquids. The above findings were reviewed with the Administrator, Executive Director, Director of Clinical Quality and Staff C, Clinical Manager

Based on personnel file review and staff interview the agency failed to ensure a registered nurse, or other appropriate skilled professionals in consultation with a registered nurse as appropriate, performed direct observation of a performance aide's performance of all required hospice aide skills on a hospice patient or pseudo-patient to determine satisfactory competency prior to allowing the hospice aide to provide care independently to hospice patients for 2 of 3 sampled hospice aides (Staff J and Staff M) hired since the last recertification survey (3/21/22). At the time of the survey, the agency employed 9 hospice aides and provided hospice aide services to 113 patients. Failure to ensure hospice aides successfully complete a competency evaluation in all basic home hospice aide skills on a patient and were competent in any assigned extra skills which exceed the level of basic hospice aide skills placed agency patients at risk to receive inadequate or unsafe hospice aide services. Findings include: --- The Medicare Conditions of Participation require hospices to ensure all newly hired hospice aides are competent in all of the basic hospice aide skills by successfully demonstrating competency in the performance of all of the "hands on" basic home health aide skills with a home health patient, exactly as these tasks will be performed with an actual home health patient, in the presence of a qualified Registered Nurse before being assigned to provide any patient care independently. The list of "hands on" basic home health aide tasks are: communication skills, reading and recording temperature, pulse, respirations, bed bath, sponge bath, tub bath and shower bath, shampoo in a sink, tub and bed, skin care, oral care, nail care, toileting and elimination, transfers/ambulation and range of motion and positioning. Basic hospice aide competencies may be demonstrated using a patient or pseudo-patient. During an interview on 2/25/24 at 3:10 PM The Director of Clinical Quality stated the hospice had no further documentation of hospice aide competencies. 1. Staff J, Hospice Aide, had a hire date of 8/19/24. Staff J's personnel file included competency documentation on 12/20/24. The competency documentation lacked competency testing for sponge bath and shampoo in sink and a written basic skills test. Staff J provided care independently to agency patients without successfully demonstrating competency in the performance of all required basic skills. 2. Staff M, Hospice Aide, had a hire date of 8/19/24. Staff J's personnel file included competency documentation on 8/27 and 8/28/24. The competency documentation lacked competency testing for sponge bath. Staff M provided care independently to agency patients without successfully demonstrating competency in the performance of all required basic skills. The above findings were reviewed with the Administrator, Executive Director, Director of Clinical Quality and Staff C, Clinical Manager.

Based on observations, staff and patient/family interviews, clinical record review and policy review, the hospice failed to ensure hospice aides provided care to the patients only as directed by the interdisciplinary group (IDG), and according to the hospice aide care plan for 10 of 14 sampled patients receiving hospice aide services (Patients #1, #2, #5, #7, #8, #11, #13, #14, #15 and #17). Failure to ensure that the hospice aide services are provided only as ordered by the physician, and according to the hospice aide care plan, increased the risk that patients personal care needs were not adequately met. --- 7. Patient #1 had a hospice admission date of 1/27/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 1/27/25 to 4/26/25, identified the patient had a diagnosis of Dementia due to Alzheimer's disease and included orders for skilled nursing and hospice aide services. b. The IDG meeting notes to update the POC, dated 2/5/25, included IDG orders for hospice aide services. c. The hospice aide task list, last reviewed on 1/28/25, included RN instructions to the hospice aide to perform the tasks assist with 1-2 person transfers to and from bed to wheelchair or recliner using gait belt, notify RN of changes to skin integrity, assist with using bedside commode, empty after use, identify date of last bowel movement, provide incontinent care when incontinent, provide pericare, change bedlinens on the first visit of the week or if appear soiled, empty trash, make bed, assist patient in wheelchair to meals if requested, feed patient with eating when present during meal or snack time, setup meal tray when present for meals, assist patient with shower, assist with brushing teeth, assist with dressing, assist with undressing, clean and file fingernails on first visit of the week, lotion to all extremities, provide bed bath, provide oral care using toothettes and shampoo hair. d. Hospice aide visit note, dated 2/5/25, identified the tasks of assist patient with a shower, assist with brushing teeth, assist with dressing, assist with undressing, lotion to all extremities, provide bed bath, provide oral cares using toothettes and shampoo hair as acknowledged but not completed; and failed to include a comment on why the task was not completed. The hospice aide failed to provide services as instructed by the RN assignment. 8. Patient #5 had a hospice admission date of 1/3/25 and received services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 1/3/25 to 4/2/25, identified the patient had a diagnosis of Dementia due to Alzheimer's disease and included orders for skilled nurse, social worker, hospice aide and chaplain services. b. The IDG meeting notes to update the POC, dated 1/8/25, 1/22/25, and 2/5/25 included IDG orders for hospice aide services. c. The hospice aide task list, last reviewed on 1/22/25, included RN instructions to the hospice aide to perform the tasks assist with 2 person transfers to and from bed to wheelchair or recliner, reposition patient, transfer patient using mechanical lift (hoyer), notify RN of changes to skin integrity, identify date of last bowel movement, provide incontinent care when incontinent, provide pericare, change bed linens if appear soiled, empty trash, make bed, assist with dressing, assist with undressing, clean and file fingernails, comb or brush hair, lotion to all extremities, provide oral care using toothettes, provide shower and shampoo hair. d. Hospice aide visit note, dated 1/7/25, identified the tasks of provide shower and shampoo were not performed and identified the task identify date of last bowel movement as acknowledged and completed. The aide failed to include a comment on why the shower and shampoo were not performed and failed to include a date of patient's last bowel movement. e. Hospice aide visit note, dated 1/10/25, identified the task identify date of last bowel movement, as acknowledged and completed; but failed to include a date. f. Hospice aide visit notes, dated 1/14/25 and 1/17/25, identified the tasks of provide shower and shampoo were not performed and identified the task identify date of last bowel movement as acknowledged and completed. The aide failed to include a comment on why the shower and shampoo were not performed and failed to include a date of patient's last bowel movement. g. Hospice aide visit notes, dated 1/21/25 and 1/24/25, identified the task identify date of last bowel movement, as acknowledged and completed; but failed to include a date. h. Hospice aide visit notes, dated 1/28/25, 1/30/25 and 2/4/25, identified the tasks of provide shower and shampoo were not performed and identified the task identify date of last bowel movement as acknowledged and completed. The aide failed to include a comment on why the shower and shampoo were not performed and failed to include a date of patient's last bowel movement. i. Hospice aide visit note, dated 2/6/25, identified the task identify date of last bowel movement, as acknowledged and completed; but failed to include a date. j. Hospice aide visit notes, dated 2/11/25 and 2/14/25, identified the tasks of provide shower and shampoo were not performed and identified the task identify date of last bowel movement as acknowledged and completed. The aide failed to include a comment on why the shower and shampoo were not performed and failed to include a date of patient's last bowel movement. The hospice aide failed to provide services as instructed by the RN assignment. 9. Patient #11 had a hospice admission date of 1/23/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 1/23/25 to 4/22/25, identified the patient had a diagnosis of Intrahepatic bile duct carcinoma and IDG orders for skilled nursing and hospice aide services. b. The IDG meeting notes to update the POC, dated 2/5/25 and 2/19/25, included orders for hospice aide services. c. The hospice aide task list, reviewed on 1/23/25, included RN instructions to the hospice aide to perform the tasks notify RN of changes to skin integrity, assist with brushing teeth, assist with dressing, assist with undressing, clean and file fingernails on first visit of the week, comb or brush hair, lotion to all extremities, provide shower, shampoo hair and identify date of last bowel movement. d. Hospice aide visit notes, dated 1/28/25, 1/31/25, 2/4/25, 2/7/25, 2/11/25, 2/14/25, 2/18/25 and 2/21/25, identified the task identify date of last bowel movement, as acknowledged and completed; but failed to include a date. e. Hospice aide visit note, dated 2/11/25, identified the aide provided patient a sponge bath; however, lacked RN instruction for this. The hospice aide failed to provide services as instructed by the RN assignment. 10. Patient #14 had a hospice admission date of 1/8/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 1/8/25 to 4/7/25, identified the patient had a diagnosis of unspecified severe protein calorie malnutrition and included orders for skilled nursing, hospice aide, social worker and chaplain services. b. The IDG meeting notes to update the POC, dated 1/22/25, 2/5/25 and 2/19/25 included IDG orders for hospice aide services. c. The hospice aide task list, reviewed on 1/8/25, included RN instructions to the hospice aide to perform the tasks assist with two person transfers to and from bed to wheelchair or recliner, reposition patient, complete catheter care, empty catheter bag, measure urine output, report to facility staff, report changes in skin integrity to facility staff, identify date of last bowel movement, provide incontinent care when incontinent, provide pericare, change bed linens if appear soiled, empty trash, make bed, assist patient in wheelchair to meals if requested, feed patient with eating when present during meal or snack time, setup meal tray when present for meals, apply heel/elbow protectors-specify which one, assist with brushing teeth, assist with dressing, assist with undressing, clean and file fingernails on first visit of the week, comb or brush hair, lotion all extremities, provide bed bath, provide oral care, provide oral care using toothettes, provide sponge bath and shampoo hair. d. Hospice aide visit note, dated 1/14/25, identified the tasks provide oral care, provide oral care using toothettes and shampoo hair as acknowledged but not completed; and failed to include a comment on why tasks were not completed. e. Hospice aide visit note, dated 1/22/25, first visit of the week, identified the tasks clean and file fingernails on first visit of week and identify date of last bowel movement as acknowledged but not completed; and failed to include a comment on why the task was not completed. f. Hospice aide visit notes, dated 1/28/25 and 1/31/25 identified the task identify date of last bowel movement, as acknowledged but not completed; and failed to include a comment on why the task was not completed. The hospice aide failed to provide services as instructed by the RN assignment. The above findings were reviewed with the Administrator, Executive Director, Director of Clinical Quality and Staff C, Clinical Manager. 3. Patient #17 had a hospice admission date of 10/9/24, a death date of 11/27/24, and, and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 10/9/24 to 1/6/25, included primary diagnosis of senile degeneration of brain and IDG orders for skilled nursing and hospice aide services. b. The IDG meeting notes to update the POC, dated, 10/16/24, 10/30/24 and 11/13/24, included IDG orders for hospice aide services. c. The undated hospice aide task list included RN instructions to the hospice aide to perform the tasks notify RN of changes to skin integrity, bathroom assistance, change brief when incontinent, identify date of last bowel movement, provide incontinent care when incontinent, provide pericare, assist with feeding, assist with dressing, assist with undressing, clean nails at each visit, file fingernails on first visit of the week, file fingernails as tolerated, lotion to all extremities, provide shower, shampoo hair and shave with electric razor. d. Hospice aide visit notes, dated 10/9/24, first visit of the week, identified the tasks notify RN of changes to skin integrity, identify date of last bowel movement, provide pericare, assist with dressing, assist with undressing, clean nails at each visit, file fingernails on first visit of the week, lotion to all extremities, provide shower and shampoo hair, as acknowledged but not completed; and failed to include a comment on why the task was not completed. e. Hospice aide visit notes, dated 10/11/24, second visit of the week, identified the tasks notify RN of changes to skin integrity, identify date of last bowel movement, assist with brushing teeth, assist with dressing, assist with undressing, clean nails at each visit, file fingernails on first visit of the week, provide shower and shampoo hair, as acknowledged but not completed; and failed to include a comment on why the task was not completed. f. Hospice aide visit note, dated 10/16/24, identified the task identify date of last bowel movement, as acknowledged and completed; but failed to include a date. g. Hospice aide visit notes, dated 10/18/24, identified the tasks notify RN of changes to skin integrity, bathroom assistance, identify date of last bowel movement, assist with feeding, assist with brushing teeth, assist with dressing, assist with undressing, clean nails at each visit, file fingernails as tolerated, provide shower and shampoo hair, as acknowledged but not completed; and failed to include a comment on why the task was not completed. h. Hospice aide visit notes, dated 10/23/24, identified the tasks notify RN of changes to skin integrity, bathroom assistance, identify date of last bowel movement, assist with brushing teeth, clean nails at each visit, file fingernails as tolerated, lotion to all extremities, provide shower, shampoo hair and shave with electric razor each visit, as acknowledged but not completed; and failed to include a comment on why the task was not completed. i. Hospice aide visit notes, dated 10/25/24, identified the tasks notify RN of changes to skin integrity, bathroom assistance, clean nails at each visit, provide shower and shampoo hair, as acknowledged but not completed; and failed to include a comment on why the task was not completed. The task identify date of last bowel movement, was acknowledged and completed but failed to include a date. j. Hospice aide visit notes, dated 10/28/24, identified the tasks notify RN of changes to skin integrity, bathroom assistance, assist with brushing teeth, clean nails at each visit, file fingernails as tolerated, lotion to all extremities, provide shower, shampoo hair and shave with electric razor, as acknowledged but not completed; and failed to include a comment on why the task was not completed. The task identify date of last bowel movement, was acknowledged and completed but failed to include a date. k. Hospice aide visit notes, dated 10/28/24, identified the tasks notify RN of changes to skin integrity, bathroom assistance, change brief when incontinent, identify date of last bowel movement, provide incontinent care, assist with feeding, encourage fluids, assist with brushing teeth, assist with dressing, assist with undressing, clean nails at each visit, file fingernails as tolerated, provide shower and shampoo hair, as acknowledged but not completed; and failed to include a comment on why the task was not completed. l. Hospice aide visit notes, dated 11/4/24, identified the tasks notify RN of changes to skin integrity, bathroom assistance, identify date of last bowel movement, assist with dressing, provide shower and shampoo hair, as acknowledged but not completed; and failed to include a comment on why the task was not completed. m. Hospice aide visit notes, dated 11/6/24 and 11/8/24, identified the tasks notify RN of changes to skin integrity, bathroom assistance, identify date of last bowel movement, assist with feeding, assist with brushing teeth, clean nails at each visit, file fingernails as tolerated, lotion to all extremities, provide shower and shampoo hair, as acknowledged but not completed; and failed to include a comment on why the task was not completed. n. Hospice aide visit notes, dated 11/11/24, identified the tasks notify RN of changes to skin integrity, bathroom assistance, assist with brushing teeth, assist with dressing, file fingernails as tolerated, provide shower and shampoo hair, as acknowledged but not completed; and failed to include a comment on why the task was not completed. The task identify date of last bowel movement, was acknowledged and completed but failed to include a date. o. Hospice aide visit notes, dated 11/13/24, identified the tasks notify RN of changes to skin integrity, bathroom assistance, change brief when incontinent, identify date of last bowel movement, provide incontinent care, assist with undressing, clean nails at each visit, file fingernails as tolerated, provide shower and shampoo hair, as acknowledged but not completed; and failed to include a comment on why the task was not completed. p. Hospice aide visit notes, dated 11/15/24, identified the tasks notify RN of changes to skin integrity, bathroom assistance, identify date of last bowel movement, provide incontinent care, assist with feeding, assist with brushing teeth, clean nails at each visit, file fingernails as tolerated, lotion to all extremities, provide shower and shampoo hair, as acknowledged but not completed; and failed to include a comment on why the task was not completed. The hospice aide failed to provide services as instructed by the RN assignment. 4. Patient #7 had a hospice admission date of 8/23/24 and received hospice services while residing in a private home. Clinical record review revealed: a. The POC, dated 8/23/24 to 11/21/24, included primary diagnosis of Parkinsons disease and interim physician orders for skilled nursing services and hospice aide services. b. The IDG meeting notes to update the POC, dated, 1/8/25, 1/22/25 and 2/5/25, included IDG orders for hospice aide services. c. The undated hospice aide task list included Registered Nurse (RN) instructions to the hospice aide to perform the tasks of brushing teeth, clean and file fingernails and nectar thick liquids per sipping cup. d. Hospice aide visit notes, dated 1/17/25 and 1/24/25, identified the tasks assist with brushing teeth and clean and file fingernails, as acknowledged but not completed; and failed to include a comment on why the task was not completed. e. Hospice aide visit note, dated 2/14/25, identified the tasks nectar thick liquids per sipping cup, assist with brushing teeth, as acknowledged but not completed; and failed to include a comment on why the tasks were not completed. The hospice aide failed to provide services as instructed by the RN assignment. 5. Patient #13 had a hospice admission date of 12/24/24 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 12/24/24 to 3/23/25, included primary diagnosis of Chronic Kidney Disease and interim physician orders for skilled nursing and hospice aide services. b. The IDG meeting notes to update the POC, dated, 1/29/25 and 2/12/25, included IDG orders for hospice aide services. c. The undated hospice aide task list included RN instructions to the hospice aide to perform the task identify date of last bowel movement. d. Hospice aide visit notes, dated 1/31/25, 2/3/25, 2/5/25, 2/7/25, 2/10/25, 2/11/25, 2/14/25, 2/17/25, 2/19/25 and 2/21/25, identified the task identify date of last bowel movement, as acknowledged and completed; but failed to include a date. The hospice aide failed to provide services as instructed by the RN assignment. 6. Patient #15 had a hospice admission date of 3/11/24, a revocation date of 4/3/24, and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 3/11/24 to 6/8/24, included primary diagnosis of heart failure and chronic kidney disease and IDG orders for skilled nursing and hospice aide services. b. The IDG meeting notes to update the POC, dated, 3/13/25 and 3/27/25, included IDG orders for hospice aide services. c. The undated hospice aide task list included RN instructions to the hospice aide to perform the tasks of brushing teeth, clean and file fingernails and nectar thick liquids per sipping cup. d. Hospice aide visit notes, dated 3/20/25 and 3/27/25, the second visits of the week, identified the task on first visit of the week, clean and file nails, as performed. The hospice aide failed to provide services as instructed by the RN assignment. Findings Include: According to the agency policy titled Interdisciplinary Group Membership and Responsibilities, dated 4/2024, the interdisciplinary group (IDG) will collaborate with the client's attending physician to develop an individualized written plan of care. The IDG group has the responsibilities of establishing the plan of care (POC) for each client admitted to hospice services, updating the POC and for the provision and supervision of all hospice care and services as directed by the POC. 1.Patient #2, had a start of care date of 8/20/24, with a primary diagnosis of Senile Degeneration of the Brain and received hospice services in a long term care facility. Clinical record review revealed the following: a. The plan of care (POC), dated 11/18/24 to 2/15/24, included Registered Nurse (RN) instructions to the hospice aide to perform the following tasks: assist the patient to meals with a wheelchair if present during mealtime, regular diet, assist with ambulation using the walker, fall precautions including ensuring the patient has the fall pendent on at all times, notification to the RN of any changes in skin integrity, universal precautions, assist with dressing, undressing, toileting to include change adult brief and provide perineal cleansing if client is incontinent, shower and shampoo hair, clean and file nails, comb/brush hair, and to apply lotion to all extremities. b. The hospice aide note, dated 12/6/24, Staff O, Hospice Aide (HA), failed to document shower and oral cares completed and lacked reasons to why tasks could not be completed. c. The hospice aide note, dated 12/11/24, Staff O, HA, failed to document oral cares, lotion to extremities, clean and file nails, and adult brief change and lacked reasons as to why tasks could not be completed. d. The hospice aide note, dated 12/23/24, Staff O, HA, failed to document oral cares, and shampoo hair and lacked reasons as to why the tasks could not be completed. The hospice failed to ensure the hospice aide provided cares to the patients as directed by the IDG. 2. Patient #18 had a start of care date of 9/20/24 and a discharge date of 10/263/24, with a primary diagnosis of late effects of a cerebral vascular accident (stroke) and received hospice services in a long term care facility. Clinical record review revealed the following: a. The POC, dated 9/20/24 to 12/17/24, included Registered Nurse (RN) instructions to the hospice aide to perform the following tasks: provide a shower or bed bath, assist patient to ambulate with a walker and gait belt, have 2 people for all transfers out of bed into the wheelchair or recliner, assist to the bathroom and provide incontinency cares, identify the date of the last bowel movement, to assist with eating, dressing, and undressing, clean and file nails, brush or comb hair, reposition, and apply lotion to all extremities. b. The hospice aide note dated 9/20/24, Staff J, HA, failed to document the tasks of clean and file nails, and identify the date of the last bowel movement and lacked a reason to why the tasks could not be completed. c. The hospice aide note dated 9/25/24, Staff J, HA, failed to document the tasks of oral cares, clean and file nails and comb/brush hair and lacked a reason as to why the tasks could not be completed. d. The hospice aide note dated 9/26/24, Staff J, HA, failed to document the tasks of oral cares, bed bath, and identify the date of the last bowel movement, and lacked a reason as to why the tasks could not be completed. e. The hospice aide note dated 9/30/24, Staff J, HA, failed to document the tasks of reposition patient, oral cares, incontinency cares, clean and file nails, and apply lotion to all extremities, and lacked a reason as to why the tasks could not be completed. d. The hospice aide note, dated 10/25/24, Staff P, HA, failed to document the task of identify the date of the last bowel movement and lacked a reason as to why the task could not be completed. The hospice failed to ensure the hospice aide provided cares to the patients as directed by the IDG.

Based on staff interview, clinical record reviews and hospice policy review, the hospice failed to ensure registered nurses performed a hospice aide supervisory visit at least once every 14 days for 5 of 13 sampled patients (Patients #7, #9, #14, #15 and #17) that required supervision. Failure to supervise hospice aides at least every 14 days placed patients at risk for a delay in identification of potential problems and/or patient needs and placed patient's at risk for not receiving the services needed to meet the assessed patient needs. Findings include: --- 3. Patient #15 had a hospice admission date of 3/11/24, a revocation date of 4/3/24, and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 3/11/24 to 6/8/24, included primary diagnosis of heart failure and chronic kidney disease and interdisciplinary group (IDG) orders for skilled nursing and hospice aide services. b. The IDG meeting notes to update the POC, dated, 3/13/25 and 3/27/25, included IDG orders for hospice aide services. c. Hospice aide visit note, dated 3/12/25, identified aide services had been provided. d. Skilled nurse visit notes, dated 3/20/25, 3/22/25 and 3/28/25, lacked documentation hospice aide supervision had been provided. e. Skilled nurse visit note, dated 4/2/25, included documentation hospice aide supervision had been completed, 21 days after the start of aide services, 7 days late. The hospice failed to document aide supervision every 14 days. 4. Patient #17 had a hospice admission date of 10/9/24, a death date of 11/27/24, and, and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 10/9/24 to 1/6/25, included primary diagnosis of senile degeneration of brain and IDG orders for skilled nursing and hospice aide services. b. The IDG meeting notes to update the POC, dated, 10/16/24, 10/30/24 and 11/13/24, included IDG orders for hospice aide services. c. Skilled nurse visit notes, dated 11/7/24 and 11/25/24, included hospice aide supervision, 18 days apart, 4 days late. The hospice failed to document aide supervision every 14 days. 5. Patient #7 had a hospice admission date of 8/23/24 and received hospice services while residing in a private home. Clinical record review revealed: a. The POC, dated 8/23/24 to 11/21/24, included primary diagnosis of Parkinsons disease and interim physician orders for skilled nursing services and hospice aide services. b. The IDG meeting notes to update the POC, dated, 1/8/25, 1/22/25 and 2/5/25, included IDG orders for hospice aide services. c. Skilled nurse visit notes, dated 1/30/25 and 2/14/25, included hospice aide supervision, 15 days apart, 1 day late. The hospice failed to document aide supervision every 14 days. Findings reviewed with the Administrator, Executive Director, Director of Clinical Quality and Staff C, Clinical Manager. According to the hospice policy, titled Clinical Field Team Member Supervision, revised 3/13/2019, a registered nurse must make 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 services ordered by the hospice interdisciplinary group met the patient's needs. The hospice aide does not have to be present during this visit. During an interview on 2/20/25 at 9:00 AM, Staff C, Clinical Manager stated the Registered Nurse (RN) Case Manager or the visiting RN complete aide supervision every 14 days. This is documented in the patient's electronical medical record. 1.Patient #9 had a hospice admission date of 10/19/24 and received hospice services while residing in a private residence. Clinical record review revealed the following: a. The Plan of Care (POC), dated 10/19/24 to 1/16/25, identified the patient had a diagnosis of Chronic Obstructive Pulmonary Disease and included orders for skilled nursing, hospice aide, music therapy and chaplain services. b. The skill nurse update to the comprehensive assessment, dated 12/27/24, signed completed by Staff F, RN, on 12/30/24 included hospice aide supervision. c. The skilled nurse visit notes, dated 12/31/24, 1/2/25, 1/7/25 and 1/9/25, failed to include hospice aide supervision. d. The skilled nurse update to the comprehensive assessment, signed completed by Staff F, RN, on 1/14/25 included hospice aide supervision (4 days late). The RN failed to supervise hospice aide services every 14 days. 2.Patient #14 had a hospice admission date of 1/8/25 and received hospice services while residing in a nursing home. Clinical record review revealed the following: a. The POC, dated 1/8/25 to 4/7/25, identified the patient had a diagnosis of unspecified severe protein calorie malnutrition and included orders for skilled nursing, hospice aide, social worker and chaplain services. b. The skilled nurse visit notes, dated 1/13/25, 1/22/25 and 1/30/25, failed to include hospice aide supervision. c. The skilled nurse update to the comprehensive assessment, signed completed by Staff F, RN, on 2/5/25 included hospice aide supervision (8 days late). The RN failed to supervise hospice aide services every 14 days.

Based on interviews, clinical record reviews and agency policy review, the hospice failed to document all required components of hospice aide supervision for 12 of 13 sampled patients (Patients #1, #2, #3, #5, #6, #7, #9, #11, #13, #14, #17 and #18) with aide services. Failure to ensure the supervision of hospice aides by registered nurses maintained documentation of a review of all required supervisory elements increased the risk of agency staff not meeting the patients' personal care needs. Findings include: --- 10. Patient #7 had a hospice admission date of 8/23/24 and received hospice services while residing in a private home. Clinical record review revealed: a. The POC, dated 8/23/24 to 11/21/24, included primary diagnosis of Parkinsons disease and interim physician orders for skilled nursing services, social work and hospice aide services. b. IDG meeting note to update the POC, dated 2/5/25, included interim physician orders for skilled nurse twice a week and hospice aide twice a week services. c. Skilled nurse visit notes, dated 12/19/24, 1/2/25, 1/16/25, 1/30/25 and 2/14/25, included documentation the hospice nurse provided aide supervision: aide followed plan of care, created successful interpersonal relationships with patient/family, complied with infection control and reported changes in patient condition. The skilled nurse visit note lacked documentation the aide demonstrated competency with assigned tasks. The hospice failed to document all required components of hospice aide supervision. 11. Patient #13 had a hospice admission date of 12/24/24 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 12/24/24 to 3/23/25, included primary diagnosis of Chronic Kidney Disease and interim physician orders for skilled nursing and hospice aide services. b. The IDG meeting notes to update the POC, dated, 1/29/25 and 2/12/25, included IDG orders for hospice aide services. c. Skilled nurse visit notes, dated 1/8/25, 1/21/25, 2/4/25 and 2/17/25, included documentation the hospice nurse provided aide supervision: aide followed plan of care, created successful interpersonal relationships with patient/family, complied with infection control and reported changes in patient condition. The skilled nurse visit note lacked documentation the aide demonstrated competency with assigned tasks. The hospice failed to document all required components of hospice aide supervision. 12. Patient #17 had a hospice admission date of 10/9/24, a death date of 11/27/24, and, and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 10/9/24 to 1/6/25, included primary diagnosis of senile degeneration of brain and IDG orders for skilled nursing and hospice aide services. b. The IDG meeting notes to update the POC, dated, 10/16/24, 10/30/24 and 11/13/24, included IDG orders for hospice aide services. c. Skilled nurse visit notes, dated 10/24/24, 11/7/24 and 11/25/24, included documentation the hospice nurse provided aide supervision: aide followed plan of care, created successful interpersonal relationships with patient/family, complied with infection control and reported changes in patient condition. The skilled nurse visit note lacked documentation the aide demonstrated competency with assigned tasks. The hospice failed to document all required components of hospice aide supervision. Findings reviewed with the Administrator, Executive Director, Director of Clinical Quality and Staff C, Clinical Manager. 8. Patient #2 had a hospice admission date of 8/20/24 and received hospice services while residing in a private long term care facility. Clinical record review revealed the following: a. The POC, dated 11/18/24 to 2/15/25, identified the patient had a diagnosis of Senile Degeneration of the Brain, and included orders for skilled nurse and hospice aide services. b. Skilled nurse visit note, dated 12/31/24, 1/14/25, 1/28/25, and 2/11/25, completed by Staff G, RN, included documentation the hospice nurse provided aide supervision: aide followed plan of care, created successful interpersonal relationships with patient/family, complied with infection control and reported changes in patient condition. The skilled nurse visit note lacked documentation the aide demonstrated competency with assigned tasks. The hospice failed to document all required components of hospice aide supervision. 9. Patient #18 had a hospice admission date of 9/19/24 and a death date of 10/26/24 and received hospice services while residing in a long term care facility. Clinical record review revealed the following: a. The Plan of Care (POC), dated , identified the patient had a diagnosis of late effects following a cerebral vascular accident (stroke), and included orders for skilled nurse and hospice aide services. b. Skilled nurse visit notes, dated 10/3/24 and 10/17/24, completed by Staff V, RN, included documentation the hospice nurse provided aide supervision: aide followed plan of care, created successful interpersonal relationships with patient/family, complied with infection control and reported changes in patient condition. The skilled nurse visit note lacked documentation the aide demonstrated competency with assigned tasks. The hospice failed to document all required components of hospice aide supervision. According to the hospice policy, titled Clinical Field Team Member Supervision, revised 3/13/2019, a registered nurse must make 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 services ordered by the hospice interdisciplinary group met the patient's needs. The supervising nurse must assess an aide's ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that include, but is not limited to: Following the patient's plan of care; creating successful interpersonal relationships with the patient and family; demonstrating competency with assigned tasks; complying with infection control policies and procedures; and reporting changes in the patient's condition. 1.Patient #1 had a hospice admission date of 1/27/25 and received hospice services while residing in a private residence. Clinical record review revealed the following: a. The Interdisciplinary Group (IDG) meeting notes, dated 2/5/25, identified the patient had a diagnosis of Dementia due to Alzheimer's disease and included orders for skilled nurse and hospice aide services. b. Skilled nurse visit note, dated 2/11/25, completed by Staff F, Registered Nurse (RN) included documentation the hospice nurse provided aide supervision: aide followed plan of care, created successful interpersonal relationships with patient/family, complied with infection control and reported changes in patient condition. The skilled nurse visit note lacked documentation the aide demonstrated competency with assigned tasks. The hospice failed to document all required components of hospice aide supervision. 2. Patient #3 had a hospice admission date of 2/7/25 and received hospice services while residing in a private residence. Clinical record review revealed the following: a. The Plan of Care (POC), dated 2/7/25 to 5/7/25, identified the patient had a diagnosis of Chronic obstructive pulmonary disease and included orders for skilled nurse and hospice aide services. b. Skilled nurse visit note, dated 2/17/25, completed by Staff U, RN, included documentation the hospice nurse provided aide supervision: aide followed plan of care, created successful interpersonal relationships with patient/family, complied with infection control and reported changes in patient condition. The skilled nurse visit note lacked documentation the aide demonstrated competency with assigned tasks. The hospice failed to document all required components of hospice aide supervision. 3. Patient #5 had a hospice admission date of 1/3/25 and received services while residing in a nursing home. Clinical record review revealed the following: a. The IDG notes, dated 1/8/25, 1/22/25 and 2/5/25, identified the patient had a diagnosis of Dementia due to Alzheimer's disease and included orders for skilled nurse and hospice aide services. b. Skilled nurse visit notes, dated 1/21/25 and 2/3/25, completed by Staff F, RN, included documentation the hospice nurse provided aide supervision: aide followed plan of care, created successful interpersonal relationships with patient/family, complied with infection control and reported changes in patient condition. The skilled nurse visit note lacked documentation the aide demonstrated competency with assigned tasks. c. Skilled nurse visit note, dated 2/13/25, completed by Staff F, RN, included documentation the hospice nurse provided aide supervision: aide created successful interpersonal relationships with patient/family, complied with infection control and reported changes in patient condition. The skilled nurse visit note lacked documentation the aide followed the plan of care and demonstrated competency with assigned tasks. The hospice failed to document all required components of hospice aide supervision. 4. Patient #6 had a hospice admission date of 1/28/25 and received services while residing in a nursing home. Clinical record review revealed the following: a. The IDG notes, dated 1/29/25 and 2/12/25, identified the patient had a diagnosis of Alzheimer's disease with early onset and included orders for skilled nurse and hospice aide services. b. Skilled nurse visit note, dated 2/13/25, completed by Staff Q, RN, included documentation the hospice nurse provided aide supervision: aide followed plan of care, created successful interpersonal relationships with patient/family, complied with infection control and reported changes in patient condition. The skilled nurse visit note lacked documentation the aide demonstrated competency with assigned tasks. The hospice failed to document all required components of hospice aide supervision. 5. Patient #9 had a hospice admission date of 10/19/24 and received hospice services while residing in a private residence. Clinical record review revealed the following: a. The IDG notes, 12/18/24, 12/31/24, 1/15/25, 1/29/25 and 2/12/25, identified the patient had a diagnosis of Chronic Obstructive Pulmonary Disease and included orders for skilled nursing and hospice aide services. b. Skilled nurse visit notes, dated 12/27/24 and 1/14/25, completed by Staff F, RN, included documentation the hospice nurse provided aide supervision: aide followed plan of care, created successful interpersonal relationships with patient/family, complied with infection control and reported changes in patient condition. The skilled nurse visit note lacked documentation the aide demonstrated competency with assigned tasks. c. Skilled nurse visit note, dated 1/28/25, completed by Staff F, RN, included documentation the hospice nurse provided aide supervision: aide created successful interpersonal relationships with patient/family, complied with infection control and reported changes in patient condition. The skilled nurse visit note lacked documentation the aide followed the plan of care and demonstrated competency with assigned tasks. d. Skilled nurse visit note, dated 2/10/25, completed by Staff F, RN, included documentation the hospice nurse provided aide supervision: aide followed plan of care, created successful interpersonal relationships with patient/family, complied with infection control and reported changes in patient condition. The skilled nurse visit note lacked documentation the aide demonstrated competency with assigned tasks. The hospice failed to document all required components of hospice aide supervision. 6. Patient #11 had a hospice admission date of 1/23/25 and received hospice services while residing in a private residence. Clinical record review revealed the following: a. The IDG note, dated 2/5/25, identified the patient had a diagnosis of Intrahepatic bile duct carcinoma and included orders for skilled nursing and hospice aide services. b. Skilled nurse visit note, dated 2/11/25, completed by Staff F, RN, included documentation the hospice nurse provided aide supervision: aide followed plan of care, created successful interpersonal relationships with patient/family, complied with infection control and reported changes in patient condition. The skilled nurse visit note lacked documentation the aide demonstrated competency with assigned tasks. The hospice failed to document all required components of hospice aide supervision. 7.Patient #14 had a hospice admission date of 1/8/25 and received hospice services while residing in a nursing home. Clinical record review revealed the following: a. The IDG notes, dated 1/22/25 and 2/5/25, identified the patient had a diagnosis of unspecified severe protein calorie malnutrition and included orders for skilled nursing and hospice aide services. b. Skilled nurse visit note, dated 2/5/25, completed by Staff F, RN, included documentation the hospice nurse provided aide supervision: aide followed plan of care, created successful interpersonal relationships with patient/family, complied with infection control and reported changes in patient condition. The skilled nurse visit note lacked documentation the aide demonstrated competency with assigned tasks. The hospice failed to document all required components of hospice aide supervision.

Based on staff interview and clinical record review the hospice failed to ensure all documentation was completed and appropriately authenticated in accordance with accepted standards of practice and agency standards for 4 of 19 sampled patients (Patients #1, #5, #9 and #15). Failure to ensure all documentation was completed, dated and signed in a timely manner decreased the ability of hospice staff to communicate and coordinate patient care effectively and to provide safe, effective hospice services to its patients. Findings include: --- 4. Patient #15 had a hospice admission date of 3/11/24, a revocation date of 4/3/24, and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 3/11/24 to 6/8/24, included primary diagnosis of heart failure and chronic kidney disease and Interdisciplinary Group (IDG) orders for skilled nursing, social work, chaplain, music therapy and hospice aide services. b. The IDG meeting note to update the POC, dated 3/13/24, included documentation massage therapy services was not applicable. c. The IDG meeting note to update the POC, dated 3/27/24, lacked documentation of IDG order for massage therapy. d. Massage therapy visit note, dated 3/29/24, identified massage therapy techniques were performed. Note was marked as completed on 4/12/25, 14 days after the visit date, 11 days late. The hospice failed to ensure timely completion of all documentation. Findings reviewed with the Administrator, Executive Director, Director of Clinical Quality and Staff C, Clinical Manager. During an interview on 2/20/25 at 9:00 AM, Staff C, Clinical Manager stated that agency goal is to have documentation completed the same day; however, staff have 72 hours to complete their documentation. Notes are authenticated with name, date, time and title of the clinician. 1.Patient #1 had a hospice admission date of 1/27/25 and received hospice services while residing in a private residence. Clinical record review revealed the following: a. The Plan of Care (POC), dated 1/27/25 to 4/26/25, identified the patient had a diagnosis of Dementia due to Alzheimer's disease and included orders for skilled nurse, social worker, hospice aide and chaplain services. b. The Chaplain initial assessment, dated 1/31/25, completed by Staff K, Chaplain, lacked a signature with name, date, time and title of clinician completing the assessment. The hospice failed to ensure all completed documentation included appropriate authentication. 2.Patient #5 had a hospice admission date of 1/3/25 and received services while residing in a nursing home. Clinical record review revealed the following: a. The POC, dated 1/3/25 to 4/2/25, identified the patient had a diagnosis of Dementia due to Alzheimer's disease and included orders for skilled nurse, social worker, hospice aide and chaplain services. b. The Chaplain initial assessment, dated 1/6/25, completed by Staff K, Chaplain, lacked a signature with name, date, time and title of clinician completing the assessment. c. The skilled nurse start of care assessment, dated 1/3/25, signed completed by Staff E, Registered Nurse (RN) on 1/16/25 (7 days late). The hospice failed to ensure timely completion and appropriate authentication of all documentation. 3.Patient #9 had a hospice admission date of 10/19/24 and received hospice services while residing in a private residence. Clinical record review revealed the following: a. The POC, dated 10/19/24 to 1/16/24, identified the patient had a diagnosis of Chronic obstructive pulmonary disease and included orders for skilled nurse, hospice aide, social worker and chaplain services. b. The Chaplain initial assessment, dated 11/25/24, completed by Staff K, Chaplain, lacked a signature with name, date, time and title of clinician completing the assessment. The hospice failed to ensure all completed documentation included appropriate authentication.

The Iowa Code, Chapter 135C.33 requires hospice agencies to complete a criminal history, a dependent adult abuse, and child abuse record check on all prospective direct or contracted employees with the potential for direct patient contact, within 30 days prior to the date of hire, using either the Iowa Single Information Repository (SING), or using both the Iowa Department of Criminal Investigation (DCI) to conduct the criminal background check, and using the Iowa Department of Human Services to conduct the dependent adult abuse and child abuse background checks. The Iowa Administrative Code, Chapter 119, requires the hospice agency to obtain authorized clearance from the Department of Human Services (DHS) prior to hiring any prospective employee who DCI has reported has a criminal record for any conviction more severe than a simple misdemeanor. Based on review of employee personnel files and staff interview, the hospice failed to ensure completion of a criminal background check for 2 of 7 sampled employees (Staff H and I) who began serving hospice patients since their last survey, dated 3/21/22. The hospice reported hiring 46 employees since the last survey. Failure to complete criminal background checks as required by Federal regulation, increased the potential risk of harm to agency patients from hospice employees who had direct patient contact. Findings include: --- According to the hospice policy titled Background Screening of Contractors and Team Members, last revised 11/2022, after an offer of employment, but before hire of any applicant, the hospice will conduct a background record check including, where applicable, a check on criminal history, a check on dependent adult abuse background, a check on professional health care licensure status, and a check on nurse aide competency. Background checks will be conducted through the use of the State on-line single contact repository system established by the Iowa Department of Inspections, Appeals and Licensing. During an interview on 2/24/25 at 3:25 PM, Human Resource staff stated the hospice found no record of the results of the criminal background check for Staff H, RN. 1. Staff I, Volunteer, had a hire date of 12/20/23. A SING criminal background check was completed using DCI and dated 1/26/24, 36 days after the hire date. The hospice failed to complete a criminal background check within 30 days prior to the date of hire. 2. Staff H, RN, had a hire date of 6/3/24. A criminal background check was completed using DCI and dated 5/10/24, and instructed the criminal background to await further information. The RN license verification, dated 7/24/24, was completed 51 days after the hire date. The hospice failed to follow through to complete further information for the criminal background check and check license verification within 30 days prior to the date of hire. Hospice staff failed to ensure the completion of a criminal history background check per Iowa law on personnel prior to allowing that person direct contact with hospice patients. The above findings were reviewed with the Administrator, Executive Director, Director of Clinical Quality and Staff C, Clinical Manager.

The Iowa Code, Chapter 135C.33 requires hospice agencies to complete a criminal history, a dependent adult abuse, and child abuse record check on all prospective direct or contracted employees with the potential for direct patient contact, within 30 days prior to the date of hire, using either the Iowa Single Information Repository (SING), or using both the Iowa Department of Criminal Investigation (DCI) to conduct the criminal background check, and using the Iowa Department of Human Services to conduct the dependent adult abuse and child abuse background checks. The Iowa Administrative Code, Chapter 119, requires the hospice agency to obtain authorized clearance from the Department of Human Services (DHS) prior to hiring any prospective employee who DCI has reported has a criminal record for any conviction more severe than a simple misdemeanor. Based on review of employee personnel files and staff interview, the hospice failed to ensure completion of a dependent adult abuse or child abuse record checks for 1 of 7 sampled employees (Staff H) who began serving hospice patients since their last survey, dated 3/21/22. The hospice reported hiring 46 employees since the last survey. Failure to complete dependent adult and child abuse record checks as required by State regulation, increased the potential risk of harm to agency patients from staff who had direct patient contact. --- According to the hospice policy titled Background Screening of Contractors and Team Members, last revised 11/2022, after an offer of employment, but before hire of any applicant, the hospice will conduct a background record check including, where applicable, a check on criminal history, a check on dependent adult abuse background, a check on professional health care licensure status, and a check on nurse aide competency. Background checks will be conducted through the use of the State on-line single contact repository system established by the Iowa Department of Inspections. Appeals and Licensing. During an interview on 2/24/25 at 3:25 PM, Human Resource staff stated the hospice found no record of the results of the criminal background check for Staff H, RN. 1. Staff H, RN, had a hire date of 6/3/24. A criminal background check was completed using DCI and dated 5/10/24, and instructed the criminal background to await further information. The hospice failed to follow through to complete further information for the criminal background check for possible department of human services evaluation within 30 days prior to the date of hire. Hospice staff failed to complete possible Department of Human Services evaluation, dependent adult and child abuse record checks within 30 days prior to the date of hire on all staff prior to hiring. The above findings were reviewed with the Administrator, Executive Director, Director of Clinical Quality and Staff C, Clinical Manager.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure hospice staff obtained a signature confirming the patient or representative of the patient received a copy of the notice of patient's rights and responsibilities for 12 of 13 (Patients #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12 and #13) sampled patients. Findings include: Review of the hospice's policy, titled Patient Bill of Rights, dated 10/2020, revealed the patient will be requested to sign the Patient Bill of Rights form. The original form will be kept in the patient's clinical record. A copy will be maintained by the patient. When the patient's representative signs the Patient Bill of Rights form, an explanation of that relationship must be documented and kept on file in the clinical record. Interview on 3/16/22 at 3:16 PM with the Hospice Quality Assurance (QA) coordinator, reported it was 2019 when staff stopped giving the patient the consent forms and solely documenting providing forms in the start of care assessments. 1. Patient #2 had a hospice admission date of 10/19/21 and received hospice services while residing in a private home. Clinical record review revealed the initial comprehensive assessment completed by a registered nurse (RN), dated 10/19/21, included documentation the nurse provided notice of rights in writing and verbally. During a home observation visit on 3/15/22 at 9:30 AM, with Staff C, RN, Staff C informed the surveyor the Medicare Benefit Election form was the only form signed on admission. The clinical record lacked documentation the hospice obtained a signature from the patient or patient representative acknowledging the receipt of the Patient Bill of Rights form. 2. Patient #7 had a hospice admission date of 8/18/21 and received hospice services while residing in a private home. Clinical record review revealed the initial comprehensive assessment completed by an RN, dated 8/18/21, included documentation the nurse provided notice of rights in writing and verbally. The clinical record lacked documentation the hospice obtained a signature from the patient or patient representative acknowledging the receipt of the Patient Bill of Rights form. 3. Patient #8 had a hospice admission date of 1/7/22 and received hospice services while residing in a private home. Clinical record review revealed the initial comprehensive assessment completed by an RN, dated 1/7/22, included documentation the nurse provided notice of rights in writing and verbally. The clinical record lacked documentation the hospice obtained a signature from the patient or patient representative acknowledging the receipt of the Patient Bill of Rights form. 4. Patient #11 had a hospice admission date of 11/10/21, a revocation date of 12/14/21 and received hospice services while residing in a private home. Clinical record review revealed the initial comprehensive assessment completed by an RN, dated 11/10/21, included documentation the nurse provided notice of rights in writing and verbally. The clinical record lacked documentation the hospice obtained a signature from the patient or patient representative acknowledging the receipt of the Patient Bill of Rights form. 5. Patient #3 had a hospice admission date of 3/2/22 and received hospice services while residing in a nursing home. Review of the clinical record on 3/15/22 revealed the following: a. The comprehensive assessment completed at the start of care by Staff E, Registered Nurse (RN), dated 3/2/22, included documentation Staff E, RN, reviewed the patient's rights and responsibilities with the patient's durable power of attorney (DPOA), gave the DPOA a copy and the DPOA verbalized understanding. The assessment included a place for the DPOA to sign agreement with the assessment information, but only included documentation of Staff E's signature. b. The clinical record lacked documentation of the DPOA's signature confirming receipt of a copy of the notice of the patient's rights and responsibilities. On 3/15/22 at 12:43 PM, during an interview, Staff E, RN, reported the patient or patient's representative signed the hospice benefit election form. She was not aware of any of form for the patient or patient representative to sign which signified they had received a copy of the patient's rights and responsibilities. On 3/16/22 at 10:20 AM, during an interview, the Clinical Manager reported the patient or patient's representative had a place to sign the comprehensive assessment at the start of care which indicated receipt of the patient's rights and responsibilities. She confirmed the nurse and not the patient or patient representative signed the comprehensive assessment agreement at the start of care for Patient #3. 6. Patient #4 had a hospice admission date of 11/9/2020 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The comprehensive assessment completed at the start of care by Staff H, RN, dated 11/9/2020, included documentation Staff H, RN, reviewed the patient's rights and responsibilities with the patient, gave the patient a copy and the patient verbalized understanding. The assessment included a place for the patient to sign agreement with the assessment information, but only included documentation of Staff H's signature. b. The clinical record lacked documentation of the patient's signature confirming receipt of a copy of the notice of the patient's rights and responsibilities. 7. Patient #10 had a hospice admission date of 5/27/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The comprehensive assessment completed at the start of care by Staff E, RN, dated 5/27/21, included documentation Staff E, RN, reviewed the patient's rights and responsibilities with the patient's DPOA, gave the DPOA a copy and the DPOA verbalized understanding. The assessment included a place for the DPOA to sign agreement with the assessment information, but only included documentation of Staff E's signature. b. The clinical record lacked documentation of the DPOA's signature confirming receipt of a copy of the notice of the patient's rights and responsibilities. 8. Patient #12 had a hospice admission date of 10/26/21, received hospice services while residing in a residential care facility and discharged from hospice services on 1/21/22. Review of the clinical record revealed the following: a. The comprehensive assessment completed at the start of care by Staff H, RN, dated 10/26/21, included documentation Staff H, RN, reviewed the patient's rights and responsibilities with the patient, gave the patient a copy and the patient verbalized understanding. The assessment included a place for the patient to sign agreement with the assessment information, but only included documentation of Staff H's signature. b. The clinical record lacked documentation of the patient's signature confirming receipt of a copy of the notice of the patient's rights and responsibilities. 9. Patient #5 had a hospice admission date of 7/18/2021 and received hospice services while residing in a nursing home. Clinical record review revealed: The initial comprehensive assessment completed by an RN, dated 7/18/21, included documentation the nurse reviewed all Patient Rights and was provided in writing in advance of furnishing care and reviewed the admission booklet and signed consents. The assessment was signed only by the nurse, not the patient. Interview on 3/16/22 at 8:53 AM with Staff B, Hospice Clinical Manager reported they incorporated into the start of care visit the admission consents and document what was provided to the patient. The patient signs the visit, so this is considered their documentation. The clinical record lacked a document containing the patient's or representative's signature confirming receipt of a copy of the notice of rights and responsibilities. 10. Patient #6 had a hospice admission date of 1/7/2022 and received hospice services while residing in a private home residence. Clinical record review revealed: The initial comprehensive assessment completed by an RN, dated 1/17/22, included documentation the nurse reviewed all Patient Rights and was provided in writing in advance of furnishing care and reviewed the admission booklet and signed consents. The assessment was signed by the nurse only and not the patient/patient representative. The clinical record lacked a document containing the patient's or representative's signature confirming receipt of a copy of the notice of rights and responsibilities. 11. Patient #9 had a hospice admission date of 2/4/2022 and received hospice services while residing in an assisted living facility. Clinical record review revealed: The initial comprehensive assessment completed by an RN, dated 2/4/22, included documentation the nurse reviewed all Patient Rights and was provided in writing in advance of furnishing care and reviewed the admission booklet and signed consents. The assessment was signed by the nurse only and not the patient/patient representative. The clinical record lacked a document containing the patient's or representative's signature confirming receipt of a copy of the notice of rights and responsibilities. 12. Patient #13 had a hospice admission date of 11/18/2021 received hospice services while residing in a private home residence and died at home on 1/1/2022. Clinical record review revealed: The initial comprehensive assessment completed by an RN, dated 11/18/21, included documentation the nurse reviewed all Patient Rights and was provided in writing in advance of furnishing care and reviewed the admission booklet and signed consents. The assessment was signed by the nurse only and not the patient. The clinical record lacked a document containing the patient's or representative's signature confirming receipt of a copy of the notice of rights and responsibilities. The above findings were reviewed with the Hospice Administrator and Hospice Clinical Manager. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview the hospice failed to ensure the completion of a drug regimen review by the Interdisciplinary Group at least every 15 days with the update to the comprehensive assessment for 3 of 13 sampled patients (Patient #1, #7 and #13). Failure to ensure the interdisciplinary group members involved in the assessment of patient needs completed all components of the drug regimen review with each update to the comprehensive assessment increased the risk of unidentified potential or actual adverse effects of medication combinations and/or ineffectiveness of medication therapy. Findings include: Review of the hospice's policy, titled Medication Profile, dated 10/2020, revealed a drug regimen review will be performed by a registered nurse at the time of initial comprehensive assessment, update to the comprehensive assessment, and with the change in the medication profile. The review will include: effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy and drug therapy currently associated with laboratory monitoring. During an interview on 3/15/22 at 2:39 PM, with the Clinical Manager, the drug regimen review is completed every 2 weeks with the Interdisciplinary Group (IDG) meeting updates, with any new or discontinued medication orders and at the time of a change in condition. 1. Patient #1 had an admission to hospice on 6/7/2019 and received services while residing in a private home residence. Clinical record review revealed: The IDG updates to the Plan of Care, dated 1/12/22, 1/26/22, and 2/9/22, included an intervention for the certification stating the drug regimen review was to include effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy and drug therapy currently associated with laboratory monitoring, every 15 days and with any medication changes, however lacked documentation the nurse completed a complete DRR. The clinical record lacked documentation of any drug regimen reviews (DRR) completed by the IDG. 2. Patient #13 had an admission to hospice on 11/18/2021, received services while residing in a private residence and died at home on 1/1/2022. Clinical record review revealed: a. The initial comprehensive assessment at start of care, dated 11/18/21, included a drug regimen review that documented review of effectives of drug therapy, drug side effects, actual or potential drug interactions, and lab monitoring. b. The initial Plan of Care, dated 11/18/21 to 2/15/21, included orders for Senna Plus and Milk of magnesia (both used for constipation) and aspirin and warfarin (both blood thinners). The initial drug regimen review, failed to document the duplicate drug therapy of meds for constipation and blood thinning as part of the DRR. c. The IDG update to the Plan of Care, dated, 11/24/21, included a DRR, however, documented duplicate drug therapy as N/A (not applicable). The IDG note, identified the patient was on aspirin and warfarin (blood thinners), Senna Plus and Milk of Magnesia (for constipation) and Tylenol and Tramadol (for pain). The IDG update to the Plan of Care, included documentation of a complete drug regimen review, however, lacked an accurate assessment of duplicate drug therapy. 3. Patient #7 had a hospice admission date of 8/18/21 and received hospice services while residing in a private home. Clinical record review revealed the following: a. The IDG meeting notes, dated 1/26/22, 2/9/22, and 3/9/22, included orders for amlodipine and hydrochlorothiazide, medications used for hypertension; and documentation no duplications noted. b. The IDG meeting note, dated 2/23/22, included orders for amlodipine and hydrochlorothiazide, medications used for hypertension; and documentation all medications reviewed for duplicate but failed to identify the duplicate medication therapy. The DRRs failed to identify the duplicate medications the patient was taking. The above findings were reviewed with the Administrator, Clinical Manager, and Quality Coordinator. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review, patient representative interview and hospice staff interview, the hospice failed to: 1) ensure all hospice services follow an individualized Plan of Care (see L0543); 2) ensure Plan of Care includes patient/family goals and interventions and include all services necessary for the palliation and management of the terminal illness and related conditions (see L0545); 3) ensure Plan of Care includes scope and frequency of services necessary to meet specific patient/family needs (see L0547); 4) ensure drugs and treatment necessary to meet the needs of the patient are provided as directed by the Interdisciplinary Group in collaboration with the attending physician (see L0549); 5) ensure the medical supplies and appliances necessary to meet the needs of the patient are provided as directed by the Interdisciplinary Group in collaboration with the attending physician (see L0550); 6) ensure the hospice Interdisciplinary Group revised the Plan of Care with information from the patient's updated comprehensive assessment and documents progress toward outcomes and goals (see L0553); and 7) ensure the hospice Interdisciplinary Group members ensured that the care and services are provided in accordance with the Plan of Care (see L0555). The cumulative effects of these systemic practices resulted in the failure of the hospice to ensure the Interdisciplinary Group of personnel promoted and supported the safe, comprehensive and effective delivery of patient care to their hospice patients.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure the provision of care in accordance with the patient's plan of care for 2 of 13 sampled (Patients #1 and #13). Failure to follow the patient's Plan of Care as directed by the Interdisciplinary Team puts the patient at risk of inconsistent care that may not meet the needs of the patient. Findings include: Review of the hospice's policy, titled The Plan of Care (POC), dated 10/2020, identified hospice staff must provide care in accordance with individualized POC. The POC will focus on identified problems, goals and interventions and include all drugs and treatments used by the patient. The Interdisciplinary Group (IDG) will update the POC no less often than every 15 days. 1. Patient #13 had a hospice admission date of 11/18/21, received hospice services while residing in a private home residence and died at home on 1/1/2022. Clinical record review revealed: a. The Plan of Care (POC), dated 11/18/21 through 2/15/22, included orders for a Point of Care International Normalized Ratio (INR) to be performed by the patient's daughter weekly and the hospice nurse to report the INR weekly to the physician for management of the warfarin dose. b. The clinical record lacked documentation of a completed POC INR and nurse documentation of a visit or communication with the physician regarding the INR for the week of 11/21/21, 12/5/21, 12/12/21, 12/19/21, and 12/26/21. Telephone interview on 3/21/22 at 9:24 AM with Staff L, Registered Nurse (RN), reported the nurse initially thought hospice nurse would call the doctor, but the patient's caregiver called the cardiologist and wished to continue. The nurse stated "I just didn't update the Plan of Care." c. The Interdisciplinary Group (IDG) update to the Plan of Care, dated 12/22/22, had the unchanged intervention for a Point of Care International Normalized Ratio (INR) to be performed by the patient's daughter weekly and the hospice nurse to report the INR weekly to the physician for management of the warfarin dose. The clinical record lacked documentation of a physician order to discontinue the intervention. The nurse failed to follow the POC. d. The Plan of Care, dated 11/18/21 through 2/15/22, included orders for oxygen 1-2 liters continuous for shortness of breath and patient may remove the nasal cannula as desired. e. A skilled nursing visit, dated 12/4/21, included documentation the patient's oxygen level was at 96% with the oxygen flow rate of 4 liters per nasal cannula as the patient's caregiver increased the flow liter to 5 liters and the nurse turned down the flow rate to 4 liters. f. The clinical record lacked documentation of a physician order for the increased rate of oxygen the nurse documented. The nurse failed to follow the POC. g. The update to the IDG dated, 12/8/21, documented the order for oxygen remained at 1-2 liters continuous for shortness of breath. The nurse's narrative stated the patient's caregiver had turned the oxygen up to 6 liters per nasal cannula and the nurse educated the caregiver to keep the oxygen liter flow under 4-5 liters. The IDG lacked an update to the order for oxygen the patient was using. h. A skilled nursing narrative note, dated 12/16/21, included documentation the nurse instructed the patient caregiver to increased the oxygen flow rate to 3 to 3.5 liters per nasal cannula due to shortness of breath. The nurse did contact the physician and requested Morphine, however the note lacked documentation of a physician's order for the increase in oxygen. i. A subsequent skilled nursing narrative note, dated 12/16/21, included documentation the nurse instructed the patient caregiver to decrease the oxygen flow rate to 2 to 2.5 liters per nasal cannula if breathing improves. The note lacked documentation of a physician's order for rate of oxygen instructed. j. The update to the IDG dated, 12/22/21, documented the order for oxygen remained at 1-2 liters continuous for shortness of breath. The nurse's narrative documented as needed oxygen to maintain oxygen saturation of greater than 90%. The IDG lacked an update to the order for oxygen the patient was using. 2. Patient #1 had a hospice admission date of 6/7/19 and received hospice services while residing in a private home residence. Clinical record review revealed: a. The Plans of Care, dated 11/23/21 through 1/21/22 and 1/22/22 to 3/22/22, included orders for oxygen 2-5 liters continuous for shortness of breath. b. A skilled nursing visit, dated 1/11/22, included documentation the patient's oxygen level was at 96% with the oxygen flow rate of 6 liters per nasal cannula. c. The clinical record lacked documentation of a physician order for the increased rate of oxygen the nurse documented. The nurse failed to follow the POC. d. The update to the IDG dated, 1/12/22, documented the order for oxygen remained at 2-5 liters continuous for shortness of breath. The nurse's narrative stated the patient respiratory status is stable at this time and the patient increases oxygen 5-6 L per nasal cannula with ambulation. The IDG lacked an update to the order for oxygen the patient was using. e. A skilled nursing visit, dated 1/16/22, included documentation the patient's oxygen level was at 92% with the oxygen flow rate of 6 liters per nasal cannula. f. A skilled nursing visit, dated 1/18/22, included documentation the patient's oxygen level was at 95% with no oxygen on room air. g. The update to the IDG dated, 1/26/22, documented the order for oxygen remained at 2-5 liters continuous for shortness of breath. The nurse's narrative stated the patient respiratory status is stable at this time and the patient increases oxygen 5-6 L per nasal cannula with ambulation. The IDG lacked an update to the order for oxygen the patient was using. h. A skilled nursing visit, dated 2/18/22, included documentation the patient's oxygen level was at 95% with oxygen at 6 liters per nasal cannula. i. The update to the IDG dated, 2/23/22, documented the order for oxygen remained at 2-5 liters continuous for shortness of breath. The nurse's narrative stated the patient respiratory status is stable at this time and the patient increases oxygen 5-6 L per nasal cannula with ambulation. The IDG lacked an update to the order for oxygen the patient was using. The surveyor reviewed the above findings with the Hospice Administrator and Hospice Clinical Manager. Hospice staff did not provide any additional findings prior to the end of the survey.

Based on clinical record review, agency policy review, observation, nursing home record review, nursing home staff interview and hospice staff interview, the hospice failed to ensure the hospice Interdisciplinary Group (IDG) developed an individualized plan of care which included goals and interventions of all services ordered and identified the assessed dietary needs of the patient for 6 of 13 sampled patients (Patients #2, #3, #4, #5, #10 and #12). Failure to establish individualized plans of care which addressed assessed needs related to the patient's dietary needs increased the potential hospice staff wound not meet the dietary needs of the patient or cause harm by not following the patient's dietary restrictions. Failure to develop a plan of care with goals and interventions for all services ordered by the IDG placed patients and families at risk for not having there assessed needs met. Findings include: Review of the hospice's policy, titled The Plan of Care (POC), dated 10/2020, identified hospice staff must provide care in accordance with individualized POC. The POC will focus on identified problems, goals and interventions and updated by the Interdisciplinary Group (IDG) no less often than every 15 days. The POC will include the identification of the patient's nutritional requirements. 1. Patient #3 had a hospice admission date of 3/2/22 and received hospice services while residing in a nursing home. Review of the clinical record on 3/15/22 revealed the following: a. The Plan of Care (POC), dated 3/2/22 to 5/30/22, identified a diagnosis of Alzheimer's and included Interdisciplinary Group (IDG) orders for home health aide services 1 time for one week, 3 times a week for one week and one time per week for a week. The POC lacked any goals or interventions for the hospice aide. The POC identified the patient had a regular diet. b. The clinical record lacked documentation of a hospice aide assignment. c. The clinical record included documentation of hospice aide visit notes completed by Staff J, Hospice Aide, dated 3/4, 3/7, 3/9, 3/11, 3/12, 3/13 and 3/14/22. The hospice aide visit notes identified the hospice aide completed a visit, but lacked any documentation on what interventions the hospice aide completed. On 3/15/22 at 11:44 AM, during an observational visit in the patient's room at the nursing home, Staff E, Registered Nurse (RN), discussed concerns with the family about a decreased appetite and intake and the patient pocketing food (keeping food in the cheek area rather than swallowing). On 3/15/22 at 12:43 PM, during an interview, Staff E, RN, explained there was a care plan/assignment for the hospice aide in her computer, and explained there was a difference between what was in the mobile application of the computer compared to the office application viewable in the electronic system. Review of the nursing home's medication and treatment order form on 3/15/22, titled Order Summary, identified a current physician's order for the patient to have a regular diet with thinned consistency (associated with patients who have difficulty swallowing) and a start date of 1/14/22. An interim physician order entered by Staff E, RN, dated 3/15/22, included a hospice aide assignment with directions for the hospice aide to assist with feeding the patient, offer fluids every 2 hours and with each meal and offer snacks between meals. On 3/16/22 at 10:20 AM, during an interview, the Clinical Manager reported the electronic system did not show evidence of a hospice aide assignment until 3/15/22. She explained if the nurse had put something in the mobile application, it would not be viewable to other staff, including the hospice aide, until the information was synced to office portion of the electronic record. On 3/16/22 at 10:57 AM, during an interview, Staff J, Hospice Aide, explained she had only been cuing the patient on taking bites during each of the visits. She reported she had not been doing anything else. When asked how she knew what to do without a written assignment prior to 3/15/22, she explained the nurse told her verbally what to do. She reported talking with the nurse daily. She further explained Staff E, RN, suggested on Friday of last week (3/11/22) to give the patient a whirlpool bath, and she gave the patient a whirlpool bath on Monday (3/14/22). On 3/16/22 at 11:56 AM, during an interview, Staff J, Hospice Aide, reported the patient was not on any special diet. The POC failed to correctly identify the special nutritional needs of the patient. 2. Patient #4 had a hospice admission date of 11/9/2020 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POCs, dated 1/3/22 to 3/3/22 and 3/4/22 to 5/2/22, included IDG orders, interventions and goals for skilled nursing, hospice aide, spiritual counseling care (SCC), social worker and music therapy services. The POCs did not identify the patient had volunteer or massage therapy services. b. Review of the clinical record identified visit notes for volunteer services, dated 1/4, 2/1, 2/8, 2/15, 3/1 and 3/8/22. c. Review of clinical record identified visit notes for massage therapy services, dated 1/6, 1/20, 1/27, 2/3, 2/10, 2/14, 2/23, 3/3 and 3/9/22. d. The IDG meetings, dated 12/29/21 and 1/12, 1/26, 2/9, 2/23 and 3/9/22, identified the hospice provided massage and volunteer services, but lacked interventions or goals for the services. 3. Patient #10 had a hospice admission date of 5/27/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 1/22/22 to 3/22/22, identified a diagnosis of Alzheimer's and a special diet of pureed food due to dysphagia. The POC included IDG orders for hospice aide services 5 times per week and instructions for the hospice aide to assist with feeding the patient. b. The clinical record included documentation Staff J, Hospice Aide, provided hospice aide visits to the patient Monday through Friday, 5 days a week, from 1/24 through 3/14/22 (with the exception of no visit on 2/11/22). Review of the nursing home's Medication Administration Record, dated March 2022, identified the patient had a pureed diet with thinned consistency. On 3/17/22 at 9:07 AM, during an interview, Staff G, Hospice Aide, reported he does assist with feeding the patient. When asked if the patient had any special diet, Staff G, Hospice Aide, reported he did not know and explained he just gave the patient whatever the nursing home provided. On 3/17/22 at 12:45 PM, during an interview, the Director of Nursing for the patient's nursing home reported the patient was on a pureed diet with thinned liquids and this had not changed since starting a pureed diet. The POC failed to fully identify the nutritional needs of the patient. 4. Patient #12 had a hospice admission date of 10/26/21, received hospice services while residing in a residential care facility and discharged from hospice services on 1/21/22. Review of the clinical record revealed the following: a. The POC, dated 10/26/21 to 1/23/22, identified the patient had a regular diet. b. The skilled nursing visit note, dated 10/27/21, included documentation which identified the patient was on a regular diet with thinned liquids. The POC failed to fully identify the nutritional needs of the patient. On 3/21/22 at 1:35 PM, during an interview, the Administrator reported hospice staff were unable to find further information. 5. Patient #2 had a hospice admission date of 10/19/21 and received hospice services while residing in a private home. Clinical record review revealed the following: a. The initial Interdisciplinary Group (IDG) meeting note, dated 10/20/21, included documentation to refer to massage therapy with an effective date of 10/19/21. b. Massage therapy visit notes, dated 1/11/22, 2/1/22, 2/15/22, 3/1/22 and 3/8/22, included documentation massage therapy was provided for the patient. c. The IDG meeting notes, dated 12/29/21, 1/12/22 and 2/23/22, lacked documentation massage therapy was provided for the patient. d. The IDG meeting notes, dated 1/26/22, included documentation massage therapy was being utilized but lacked documentation of massage therapy services frequency, interventions and goals. e. The IDG meeting note, dated 2/9/22, included documentation massage therapy was increased to weekly but lacked documentation of massage therapy services interventions and goals. f. The IDG meeting note, dated 3/9/22, included documentation massage therapy missed one visit as patient was not home when therapist arrived but lacked documentation of massage therapy frequency, interventions and goals. 6. Patient #4 had a hospice admission date of 7/18/2021 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plans of Care (POC), dated 7/18/21 to 10/15/21, 10/16/21 to 12/14/21, 12/15/21 to 2/12/22, identified the patient's nutrition requirements as dysphagia and nutritional supplements. b. The initial comprehensive assessment, dated 7/18/21 and completed by the nurse, documented the patient was on a pureed diet with thin liquids. The Plan of Care lacked identification of the prescribed diet the patient was receiving at the nursing home. During surveyor observation of the IDG on 3/9/2022, the IDG did discuss the patient's altered diet. The above findings were reviewed with the Hospice Administrator and Hospice Clinical Manager. Hospice staff provided no additional information prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure the hospice Interdisciplinary Group developed patient plans of care which specified the scope and frequency for all services required by and provided to patients for 3 of 13 sampled patients (Patients #2, #4 and #12). Failure to identify a scope and frequencies for all ordered services increased the potential for hospice services to not adequately meet the needs of hospice patients and families. Findings include: Review of the hospice's policy, titled The Plan of Care (POC), dated 10/2020, identified hospice staff must provide care in accordance with individualized POC. The POC will include the frequency, amount and duration of services and updated by the Interdisciplinary Group (IDG) no less often than every 15 days. 1. Patient #4 had a hospice admission date of 11/9/2020 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POCs, dated 1/3/22 to 3/3/22 and 3/4/22 to 5/2/22, included IDG orders, interventions and goals for skilled nursing, hospice aide, spiritual counseling care (SCC), social worker and music therapy services. The POCs did not identify the patient had volunteer or massage therapy services. b. Review of the clinical record identified visit notes for volunteer services, dated 1/4, 2/1, 2/8, 2/15, 3/1 and 3/8/22. c. Review of clinical record identified visit notes for massage therapy services, dated 1/6, 1/20, 1/27, 2/3, 2/10, 2/14, 2/23, 3/3 and 3/9/22. d. The IDG meetings, dated 12/29/21 and 1/12, 1/26, 2/9, 2/23 and 3/9/22, identified the hospice provided massage and volunteer services, but lacked a scope and frequency for the services. 2. Patient #12 had a hospice admission date of 10/26/21, received hospice services while residing in a residential care facility and discharged from hospice services on 1/21/22. Review of the clinical record revealed the following: a. The POC, dated 10/26/21 to 1/23/22, included IDG orders for skilled nursing, SCC and social worker services. The POC identified bereavement needs related to allowing expression of feeling by the patient/family. b. The comprehensive assessment completed by a nurse at the start of care, dated 10/26/21, included documentation of a bereavement risk assessment for the patient's spouse. c. A bereavement care clinical note, dated 11/12/21, included documentation of a bereavement risk assessment for the patient due to the loss of the patient's spouse. The risk assessment identified the patient was low risk. d. The IDG meeting, dated 11/17/21, included the addition of the "bereavement coordinator". The IDG meeting failed to include any information regarding the scope and frequency for bereavement care services. e. The clinical record included documentation of bereavement care visit notes, dated 11/19, 11/22, 11/23, 11/29, 12/3 and 12/6/21 and 1/3/22. f. The IDG meetings, dated 12/1, 12/15 and 12/29/21 and 1/12/22, did not identify a scope and frequency for bereavement care services. On 3/17/22 at 8:13 AM, during an interview, Staff M, Bereavement Coordinator, reported she had only been in the position for the last month and could not answer any patient specific questions for something that occurred prior to her taking over the position. She explained hospice staff based bereavement care services on the bereavement risk assessment. Hospice staff complete an initial assessment upon admission to hospice and then another assessment after the death. 3. Patient #2 was admitted to hospice on 10/19/21 and received services while residing in a private home. Clinical record review revealed the following: a. The initial Interdisciplinary Group (IDG) meeting note, dated 10/20/21, included documentation to refer to massage therapy with an effective date of 10/19/21. b. Massage therapy visit notes, dated 1/11/22, 2/1/22, 2/15/22, 3/1/22 and 3/8/22, included documentation massage therapy was provided for the patient. c. The IDG meeting notes, dated 12/29/21, 1/12/22 and 2/23/22, lacked documentation massage therapy was provided for the patient. d. The IDG meeting notes, dated 1/26/22, 2/9/22 and 3/9/22, included documentation massage therapy was being utilized but lacked documentation of a frequency for massage therapy services. The above findings were reviewed with the Administrator, Clinical Manager, and Quality Coordinator. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, home visit observation, hospice policy review, and hospice staff interview, the hospice failed to ensure the hospice plan of care included all necessary medications and treatments and/or a complete order for all medications and treatments to meet the needs of the patient for 1 of 3 sampled patients with home visit observations (Patient #1). Failure to ensure the plan of care included physician orders for all necessary medications and and complete orders for medications placed patients at risk to receive inappropriate treatment of symptoms. Findings include: Review of the hospice's policy, titled The Plan of Care (POC), dated 10/2020, identified hospice staff must provide care in accordance with individualized POC. The POC will include all drugs and treatments used by the patient. The Interdisciplinary Group (IDG) will update the POC no less often than every 15 days. Patient #1 had a hospice admission date of 6/7/19 and received hospice services while residing in a private home residence. During a home visit observation on 3/15/22 at 8:25 AM with Staff D, Registered Nurse (RN), the surveyor observed the nurse supervising the patient setting up medication planners. The patient had a container to store all medications in. The container included a prescription bottle of Senna S 8.6 milligrams (mg)-50 mg with orders to take 1 daily as needed for constipation. The bottle had a fill date of 1/19/22. Interview with the nurse reported the patient only takes the Senna S when the Colace does not work. a. Hospice Medication Profile list, lacked documentation of the patient's use of Senna S. b. The IDG updates to the Plan of Care, dated 1/26/22, 2/9/22, 2/23/22, and 3/9/22, lacked identification of the patient's use of Senna S. The above findings were reviewed with the Hospice Administrator and Hospice Clinical Manager. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, home visit observation, hospice policy review and patient and hospice staff interview, the hospice failed to ensure the Plan of Care for 3 of 13 sampled patients (Patients #1, #2 and #6) included all medical equipment and supplies necessary to meet identified patient needs. Failure to include all needed items of medical equipment and supplies the patient used on the Plans of Care placed the patients at risk of unanticipated decline or injury and of needs not met. Findings include: Review of the hospice's policy, titled The Plan of Care (POC), dated 10/2020, identified hospice staff must provide care in accordance with individualized POC. The POC will include identification of the medical equipment and supplies necessary to meet the needs of the patient. 1. Patient #1 had a hospice admission date of 6/7/19 and received hospice services while residing in a private home residence. Clinical record review revealed: a. The Plan Of Cares (POCs), dated 9/24/21 to 11/22/21 and 11/23/21 to 1/21/22, and 1/22/22 to 3/22/22, identified the patient used the following medical equipment and supplies: gloves, oxygen and supplies, nebulizer and supplies, personal protective equipment, wheeled seated walker, shower chair, lift chair, urinal, pantiliners, and wheelchair. b. The Interdisciplinary Group (IDG) update to the Plan of Care, dated 1/26/22, documented durable medical equipment (DME) changes included a hospital bed and bedside commode. During a home visit observation on 3/15/22 at 8:25 AM with Staff D, Registered Nurse (RN), the surveyor observed the following additional medical equipment in the home: a hospital bed with bed rails and an air mattress. Interview with the patient reported the bed rails and air mattress have been in place since the end of January 2021. c. The POC dated 1/22/22 to 3/22/22 and IDG updates to the POC, dated 1/26/22, 2/9/22, 2/23/22, and 3/9/22, lacked identification of the patient's use of side rails and an air mattress as equipment/supplies used to meet the patient's needs. During the same home visit observation the surveyor observed the nurse monitoring the patient setting up the ordered medications in medication planners. The nurse reported the patient's use of medication planners since prior to the nurse taking over care for the patient in June of 2021. The POCs dated 9/24/21 to 11/22/21, 11/23/21 to 1/21/22, and 1/22/22 to 3/22/22 and IDG updates to the POC, dated 1/26/22, 2/9/22, 2/23/22, and 3/9/22, lacked identification of the patient's use of medication planners as equipment/supplies used to meet the patient's needs. 2. Patient #6 had a hospice admission date of 1/17/22 and received hospice services while residing in a private home residence. Clinical record review revealed: a. The POC, dated 1/17/22 to 4/16/22, identified the patient used the following medical equipment and supplies: gloves, and a walker. b. The skilled nurse visit notes, dated 1/21/22, 2/3/22, documented the patient's use of incontinence supplies. c. The skilled nurse visit notes, dated 1/27/22, 2/8/22, 2/10/22, and 2/24/22, documented the patient's use of incontinence supplies and medication planner. d. The skilled nurse clinical note, dated 2/3/22, documented the patient's use of medication planner set up by the nurse. The IDG updates to the POC, dated 1/26/22, 2/9/22, 2/23/22, and 3/9/22, lacked identification of the patient's use of incontinence supplies and medication planners as equipment/supplies used to meet the patient's needs. 3. Patient #2 had a hospice admission date of 10/19/21 and received hospice services while residing in a private home. a. Clinical record review revealed the revised Plan of Care, dated 1/17/22 to 4/16/22, included documentation the patient had non-sterile gloves, kling non-sterile, sterile 4x4 gauze,, shower chair, hand held shower head, donut cushion, rollator walker, waffle cushion, outdoor wheelchair ramp, wheelchair, paracentesis supplies, wound supplies, oxygen supplies, incentive spirometer, basic recliner, lift chair, gel cushion, hospital bed, incontinent supplies, bedside commode, over the bed table, and compression socks, as medical equipment and supplies use by the patient. b. During a home observation visit on 3/15/22 at 9:30 AM, with Staff C, RN, surveyor observed the patient's hospital bed with an alternating air flow mattress and a quarter side rail. The bathroom shower had 2 grab bars used by the patient when showering and a raised toilet seat with side hand rails. The patient reported the air flow mattress and side rail came with the hospital bed that was delivered at the time of admission to hospice and the toilet seat was added when the patient became strong enough to walk into the bathroom and no longer needed the bedside commode, approximately the past several months. c. The IDG meeting notes, dated 12/29/21, 1/12/22, 1/26/22, 2/9/22, 2/23/22 and 3/9/22, lacked documentation of the air mattress, quarter side rail, grab bars or raised toilet seat as medical equipment used by the patient. The Plan of Care and IDG meeting notes failed to identify all necessary medical equipment and supplies used by the patient. The above findings were reviewed with the Administrator, Clinical Manager, and Quality Coordinator. On 3/21/22 at 1:35 PM, during an interview, the Administrator reported hospice staff were unable to find further information.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure the hospice Interdisciplinary Group revised the patient's plan of care based on the updated comprehensive assessment and include the patient's progress towards outcomes and goals specified in the plan of care for 3 of 12 sampled patients (Patients #2, #4 and #12) requiring an updated comprehensive assessment. Failure of the hospice to ensure the Interdisciplinary Group (IDG) revised the patient's plan of care based on the updated comprehensive assessment and include patients' progress towards outcomes and goals placed patients at risk to not receive care and services based on their current assessed needs. Findings include: Review of the hospice's policy, titled The Plan of Care (POC), dated 10/2020, identified hospice IDG staff will develop an individualized POC based on the comprehensive assessment and updates to the comprehensive assessment performed by members of the IDG. The IDG will review and revise the POC as frequently as necessary, but no less often than every 15 days. The POC will focus on problems, interventions and goals. The IDG will monitor each patient for his/her response to care or services against established goals and outcomes to evaluate progress towards goals. 1. Patient #4 had a hospice admission date of 11/9/2020 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POCs, dated 1/3/22 to 3/3/22 and 3/4/22 to 5/2/22, included IDG orders, interventions and goals for skilled nursing, hospice aide, spiritual counseling care (SCC), social worker and music therapy services. The POCs did not identify the patient had volunteer or massage therapy services. b. Review of the clinical record identified visit notes for volunteer services, dated 1/4, 2/1, 2/8, 2/15, 3/1 and 3/8/22. c. Review of clinical record identified visit notes for massage therapy services, dated 1/6, 1/20, 1/27, 2/3, 2/10, 2/14, 2/23, 3/3 and 3/9/22. d. The IDG meetings, dated 12/29/21 and 1/12, 1/26, 2/9, 2/23 and 3/9/22, identified the hospice provided massage and volunteer services, but lacked any information on interventions, goals or patient progress. 2. Patient #12 had a hospice admission date of 10/26/21, received hospice services while residing in a residential care facility and discharged from hospice services on 1/21/22. See L0547 for evidence for Patient #12. The IDG meetings, dated 12/1, 12/15 and 12/29/21 and 1/12/22, identified the patient had a bereavement coordinator, but lacked any information on interventions provided by the bereavement coordinator or patient progress. On 3/21/22 at 1:35 PM, during an interview, the Administrator reported hospice staff were unable to find further information. 3. Patient #2 had a hospice admission date of 10/19/21 and received hospice services while residing in a private home. Clinical record review revealed the following: a. The initial Interdisciplinary Group (IDG) meeting note, dated 10/20/21, included documentation to refer to massage therapy with an effective date of 10/19/21. b. The Plan of Care, dated 1/17/22 to 4/16/22, included IDG orders for interventions and goals for skilled nursing, chaplain, social worker, hospice aide and music therapy services. c. The IDG meeting notes, dated 12/29/21, 1/12/22, 1/26/22, 2/9/22, 2/23/22 and 3/9/22, included documentation of IDG orders for interventions and goals for skilled nursing, chaplain, social worker, hospice aide and music therapy services. d. Massage therapy visit notes, dated 1/11/22, 2/1/22, 2/15/22, 3/1/22 and 3/8/22, included documentation massage therapy was provided for the patient. e. The IDG meeting notes, dated 12/29/21, 1/12/22 and 2/23/22, lacked documentation massage therapy was provided for the patient. f. The IDG meeting notes, dated 1/26/22, 2/9/22 and 3/9/22, included documentation massage therapy was being utilized but lacked documentation of IDG orders for frequency, interventions and goals for massage therapy services. The above findings were reviewed with the Administrator, Clinical Manager, and Quality Coordinator. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure coordination and collaboration among Interdisciplinary Group members occurred to ensure patient plan of care was followed for 9 of 13 sampled hospice patients (Patients #2, #4, #5, #6, #7, #10, #11, #12, and #13). Failure of the hospice team members to coordinate and collaborate services and communicate effectively increased the risk that patients did not receive services to meet needed services. Findings include: According to the hospice policy, titled Skin Management, dated 2/2022, a comprehensive wound assessment will be completed weekly to include assessment of wound bed, wound edges, peri-wound, drainage, odor, signs and symptoms of infection, and measurements (length, width and depth) unless orders from a physician direct otherwise. Review of the hospice's policy, titled The Plan of Care (POC), dated 10/2020, identified hospice staff must provide care in accordance with individualized POC. The POC will identify the needs and services to meet those needs and include a detailed scope and frequency of services. The IDG will review and revise the POC as frequently as necessary, but no less often than every 15 days. 1. Patient #5 had an admission to hospice on 7/18/2021 and received services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care, dated 2/13/22 to 4/13/22, included an order for skilled nursing visits 4 times per week for one week, then 7 times per week for 8 weeks. b. The skilled nurse visit notes, for the week of 2/20/22, documented visits occurred on 2/21/22, 2/22/22, 2/23/22, and 2/24/22. c. The skilled nurse patient note, dated 2/20/22, documented the visit was canceled by the licensed practical nurse because it was not necessary. d. An interim physician's order, dated 2/24/22, decreased the visit frequency to 3 times per week. e. The IDG update to the Plan of Care, dated 3/2/22, documented no missed skilled nurse visits in the two week time period before the IDG. The nurse failed to provide services in accordance with the plan of care and notify IDG of the missed skilled nurse visit. 2. Patient #6 had an admission to hospice on 1/7/2022 and received services while residing in a private home residence. Clinical record review revealed: a. The Plan of Care, dated 1/17/22 to 4/16/22, included an order for skilled nursing visits 2 times per week for 13 weeks and home health aide visits three times per week for 13 weeks. b. The skilled nurse visit note, for the week of 2/20/22, documented only one skilled nurse visit occurred on 2/24/22. c. The skilled nurse clinical note, dated 2/22/22, documented the visit was missed due to the licensed practical nurse being sick and the clinical manager contacted the patient and the caregiver said no visit was necessary. d. The IDG updates to the Plan of Care, dated 2/23/22 and 3/9/22, documented no missed skilled nurse visits in the two week time period before the IDGs. The nurse failed to provide services in accordance with the plan of care and notify IDG of the missed skilled nurse visit. e. The home health aide visit notes, for the week of 2/20/22, documented only two home health aide visits occurred on 2/21/22 and 2/25/22. f. The IDG update to the Plan of Care, dated 3/9/22, documented no missed hospice aide visits in the two week time period before the IDG. The hospice aide failed to provide services in accordance with the plan of care and notify IDG of the missed hospice aide visit. 3. Patient #13 had an admission to hospice on 11/18/2021, received services while residing in a private home residence and died at home on 1/1/2022. Clinical record review revealed: a. The Plan of Care, dated 11/18/21 to 2/15/22, included an order for skilled nursing visits 2 times per week for 8 weeks. b. The skilled nurse visit note, for the week of 12/20/21, documented only one skilled nurse visit occurred on 12/24/21. c. The skilled nurse clinical note, dated 12/23/21, documented a phone call to the patient's caregiver, however no visit was made.. d. The IDG updates to the Plan of Care, dated 12/22/21 and 1/5/22, documented no missed skilled nurse visits in the two week time period before the IDGs. The nurse failed to provide services in accordance with the plan of care and notify IDG of the missed skilled nurse visit. 4. Patient #4 had a hospice admission date of 11/9/2020 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 1/3/22 to 3/3/22, included IDG orders, interventions and goals for skilled nursing, hospice aide, spiritual counseling care (SCC), social worker and music therapy services. The POC included IDG orders for music therapy 1 time per week for 9 weeks. b. The clinical record lacked documentation of a music therapy visit the week of 2/13/22. c. The subsequent IDG meeting, dated 2/23/22, lacked documentation of IDG awareness of the missed music therapy visit the week of 2/13/22. 5. Patient #10 had a hospice admission date of 5/27/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 1/22/22 to 3/22/22, included IDG orders for skilled nursing services, hospice aide services 5 times per week, music therapy, social work and SCC services. The POC included orders for the hospice aide to complete the following tasks: provide incontinence care as needed if soiled, passive range of motion to all extremities, transfer using 2 people with the Hoyer lift, place call bell within reach, set up tray and assist feed patient, seated shower, shampoo hair, apply lotion to all extremities, assist with dressing and undressing, comb or brush hair, brush teeth, assist with shaving razor on chin hair, clean and file fingernails, report skin breakdown or redness to registered nurse (RN). b. The clinical record included documentation of 4 hospice aide visits the week of 2/7/22, dated 2/7, 2/8, 2/9 and 2/10. c. The subsequent IDG meeting, dated 2/23/22, lacked documentation of IDG awareness of the missed hospice aide visit the week of 2/7/22. 6. Patient #12 had a hospice admission date of 10/26/21, received hospice services while residing in a residential care facility and discharged from hospice services on 1/21/22. Review of the clinical record revealed the following: a. The POC, dated 10/26/21 to 1/23/22, included IDG orders for skilled nursing, SCC and social worker services. b. The IDG meeting, dated 11/3/21, included IDG orders for hospice aide services 1 time for 1 week on 11/3/21. The IDG meeting included no further information about hospice aide services. c. The clinical record lacked documentation of a hospice aide services provided on or around the date of 11/3/21. d. The subsequent IDG meeting, dated 11/17/21, lacked documentation of IDG awareness of the missed hospice aide visit on 11/3/21. On 3/21/22 at 1:35 PM, during an interview, the Administrator reported hospice staff were unable to find further information. 7. Patient #2 had a hospice admission date of 10/19/21 and received hospice services while residing in a private home. Clinical record review revealed the following: a. The Plan of Care, dated 1/17/22 to 4/16/22, included IDG orders for hospice skilled nurse services 2 times per week. b. The week of 2/13/22 to 2/19/22, included documentation of one skilled nurse visit, dated 2/15/22, and one missed skilled nurse visit on 2/18/22. c. The IDG meeting note, dated 2/23/22, failed to include documentation which identified the IDG was aware of the missed skilled nurse visit the week of 2/13/22. 8. Patient #7 was admitted to hospice on 8/18/21 and received services while residing in a private home. Clinical record review revealed the following: a. The Plan of Care, dated 11/16/21 to 2/13/22, included orders for skilled nursing visits 1 time a week for 14 weeks. b. Skilled nursing visit notes, dated 1/12/22, 1/27/22 and 2/9/22, included documentation nursing services were provided. The clinical record lacked documentation of a skilled nursing visit for the weeks of 1/16/22 to 1/22/22 and 1/30/22 to 2/5/22. c. The IDG meeting notes, dated 1/26/22 and 2/9/22, failed to identify the missed skilled nursing visits for the weeks of 1/16/22 and 1/30/22. d. The weeks of 2/20/22 and 2/27/22 lacked documentation of skilled nursing visits or documentation of canceled skilled nursing visits. d. The IDG meeting notes, dated 2/23/22 and 3/9/22, failed to identify the missed skilled nursing visits for the weeks of 2/20/22 to 2/26/22 and 2/27/22 to 3/5/22. During an interview on 3/15/22 at 3:00 PM, the Clinical Manager reported the patient had traveled outside the hospice service area on the weeks of 2/20/22 and 2/27/22 to visit family. The patient traveled outside the service area at other times but the Clinical Manager was not aware of those dates, she would need to review the chart to see if this would account for the missed visits on the weeks of 1/16/22 and 1/30/22. 9. Patient #11 had a hospice admission date of 11/10/21, a revocation date of 12/14/21 and received hospice services while residing in a private home. Clinical record review revealed the following: a. The Plan of Care, dated 1/17/22 to 3/17/22, included IDG orders for hospice skilled nurse services 1 time per week and hospice aide services 3 times per week. b. The skilled nurse visit note, dated 11/23/22, included documentation of right buttock wound measuring 1 cm (centimeter) x 1 cm. c. The skilled nurse visit note, dated 11/30/22, included documentation of right buttock wound measuring 0.5 cm x 0.5 cm x 0 cm. d. The IDG meeting note, dated 12/1/21, failed to include documentation of the right buttock wound depth. e. Patient note, dated 11/17/21, included documentation of a canceled hospice aide visit on 11/17/21. f. The IDG meeting note, dated 12/1/21, failed to include documentation of the missed hospice aide visit on 11/17/21. The above findings were reviewed with the Administrator, Clinical Manager, and Quality Coordinator. Hospice staff provided no further information prior to the end of the survey.

Based on review of clinical record documentation, policy review and staff interview, the hospice failed to ensure hospice staff followed the Interdisciplinary Group (IDG) bereavement plan of care according to identified needs and risks of the bereaved. The survey identified this concern with 1 of 3 sampled bereavement records (Patient #16). Failure to provide bereavement counseling according to identified needs, placed the bereaved at increased risk for worsening or unresolved issues related to grief. Findings include: Review of the hospice's policy, titled Bereavement Services, dated 10/2020, identified hospice staff would provide bereavement services before and after the patient's death in accordance with the plan of care and based on the assessed needs of the family/caregiver. Bereavement services can last up to 1 year following the patient's death. Patient #16 had a hospice admission date of 11/15/21 and died on 11/21/21. Review of the clinical record for bereavement services provided to the family after the patient's death revealed the following: A bereavement care clinical note, dated 11/23/21, identified the Bereavement Coordinator made an initial phone contact with the primary family members identified by the hospice IDG to receive bereavement services. The family members reported being open to receiving another bereavement phone call after the patient's funeral. The Bereavement Coordinator documented she identified the family members as "low risk" for the bereavement assessment, had an "excellent" coping status and a plan to next call the bereaved family members on 12/3/21. The clinical record lacked any further documentation of contact with the patient's bereavement family members. On 3/17/22 at 8:13 AM, during an interview, Staff M, Bereavement Coordinator, reported she had only been covering this position for the last month, as the previous person was out on medical leave with a plan to return to the hospice. She explained she provided bereavement care and services according to the plan of care. She identified hospice staff completed the initial bereavement risk assessment upon admission to hospice and then hospice staff reevaluated the bereavement risk after the patient's death. She was not able to provide any further information on this patient. She reported there was a computer spreadsheet that tracked routine mailings sent to the bereaved. She advised the surveyor talk with the Administrator for further information. On 3/17/22 at 10:10 AM, during an interview, the Administrator reported the hospice staff sent the bereavement family members routine mailings on 12/5/21, 12/21/21 and a 3 month mailing on 2/21/22. She reported an inability to find documentation of contact or an attempt to contact the bereaved family members on or after 12/3/21. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to: 1) ensure hospice aides satisfactorily demonstrated competency in the performance of any skills which exceed the level of basic hospice aide skills in the presence of a registered nurse prior to being assigned to perform the task independently (L0615); 2) ensure the registered nurse provided written hospice aide instructions specific to the needs of each patient (L0625); and 3) ensure the hospice aide provided services as directed by the hospice aide care plan (L0626). The cumulative effects of these systemic practices resulted in the failure of the hospice to ensure hospice aides provided patient care in a manner to meet the individualized needs of all patients effectively and safely.

Based on clinical record review, observation, review of employee personnel files, review of nursing home's physician order summary, nursing home staff interview and hospice staff interview, the hospice failed to ensure 3 of 5 sampled hospice aides (Staff F, G and J) satisfactorily demonstrated competency in the performance of any skills which exceed the level of basic hospice aide skills in the presence of a registered nurse with competency determined at a patient's bedside, oral examination or with a pseudo-patient prior to being assigned to perform the task independently for 3 of 9 sampled patients who required an extra skill task to be performed (Patients #3, #4 and #10). The hospice employed a total of 5 aides at the time of the survey. The hospice reported a total of 49 patients received hospice aide services at the time of the survey. Failure to ensure hospice aides have a competent ability to perform all skills above and beyond basic hospice aide skills increased the risk that patients received inadequate or inappropriate care. Findings include: The Medicare Conditions of Participation direct that the hospice aide may not independently provide any patient cares beyond the basic required skills without successful instruction and demonstration of competency in extra skills assigned on the aide care plan. 1. Patient #3 had a hospice admission date of 3/2/22 and received hospice services while residing in a nursing home. See L0545 evidence for Patient #3. Review of the personnel file for Staff J, Hospice Aide, identified a hire date of 10/28/2011. The file included documentation Staff J, Hospice Aide, had completed a competency evaluation in providing feeding assistance to patients, but lacked documentation Staff J had been provided competency training and evaluation on a regular diet with thinned consistency. 2. Patient #4 had a hospice admission date of 11/9/2020 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 1/3/22 to 3/3/22, identified diagnoses of Parkinson's and dysphagia (difficulty swallowing) and included orders for hospice aide services 3 times per week. The POCs identified the patient had a regular diet included orders for the hospice aide to assist the patient with feeding and offer fluids every 2 hours and with each meal. b. The IDG meeting, dated 1/26/22, identified the patient's diet changed to mechanical soft with nectar thick liquids and instructions for the hospice aide to assist with feeding the patient and offer fluids every 2 hours with each meal. The IDG meeting also included instructions for the hospice aide to encourage use and assist patient with use of the incentive spirometer for 10 repetitions every 2 hours while awake. c. The clinical record included documentation Staff F, Hospice Aide, had provided hospice aide services to the patient. On 3/16/22 at 12:49 PM, during an interview, Staff F, Hospice Aide, reported she was aware the patient had a special diet of mechanical soft with nectar thick liquids. She reported she made sure the patient had nectar thick liquids prior to giving them to the patient. She reported receiving annual training on the different diets. Review of the personnel file for Staff F, Hospice Aide, identified a hire date of 12/9/19. The file included documentation Staff F, Hospice Aide, had completed a competency evaluation in providing feeding assistance to patients, but lacked documentation Staff F had been provided competency training and evaluation on a mechanical soft diet with nectar thick liquids. The personnel file for Staff F, Hospice Aide, lacked a competency evaluation in the use of the incentive spirometer. On 3/21/22 at 11:20 AM, during an interview, the Administrator reported an inability to find a competency evaluation for Staff F, Hospice Aide, in the use of the incentive spirometer. She reported an inability to find documentation of any training or competency evaluations on the special diets of the patients for any of the hospice aides. 3. Patient #10 had a hospice admission date of 5/27/21 and received hospice services while residing in a nursing home. See L0545 for evidence for Patient #10. Review of the personnel file for Staff G, Hospice Aide, identified a hire date of 11/26/18. The file included documentation Staff G, Hospice Aide, had completed a competency evaluation in providing feeding assistance to patients, but lacked documentation Staff G had been provided competency training and evaluation on a pureed diet with thinned consistency. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the registered nurses developed individualized patient specific written instructions directing the care provided by each hospice aide for 3 of 10 sampled patients receiving hospice aide services. (Patients #3, #4, and #5). The hospice reported a total of 49 patients received hospice aide services at the time of the survey. Failure to provide patient specific, written instructions for hospice aides, directing them which tasks to perform and how frequently, for each patient; increased the risk hospice patients did not receive the services as ordered by the patient's physician and by the Interdisciplinary Group (IDG) Care Plan, to meet each patient's needs. Findings include: According to the hospice policy, titled Hospice Aide Services, dated 10/2020, hospice aide assignments, plan of care, and interventions will be documented and included in the patient's clinical record. Hospice aides will document care provided in accordance with the hospice aide assignment. During an interview on 3/15/22 at 2:39 PM, with the Clinical Manager, the registered nurse (RN) creates the hospice aide care plan, the care plan is reviewed every 2 weeks, the hospice aide should document if the task was completed or not completed and if not completed the aide should notify the RN. If the aide is requested to complete a task not on the care plan, the aide would call the RN. 1. Patient #5 had a hospice admission date of 7/18/2021 and received services while residing in a private home residence. Clinical record review revealed: a. The Plans Of Care, dated 12/15/21 to 2/12/22 and 2/13/22 to 4/13/22, included IDG orders for skilled nursing and hospice aide services and documented activities permitted as transfer bed to chair, wheelchair, and hoyer lift. b. The Hospice Aide Care Plan, for the certification periods, 12/15/21 to 2/12/22 and 2/13/22 to 4/13/22, included the following tasks for the home care aide: place call light within reach, change brief if soiled, measure and report urine output each shift and as needed, suprapubic catheter care with bathing, set up tray and assist feeding the patient, offer fluids every 2 hours and with meals, apply lotion to all extremities, assist with dressing and undressing the patient, apply heel protectors, provide back rub, and clean and file nails as directed by caregiver. Interview on 3/16/22 at 11:56 AM with Staff J, Hospice Aide, reported the aide does transfer patient with the hoyer lift and has used the hoyer lift since the patient's admission to the agency in July of 2021. Interview on 3/16/22 at 2:05 PM with Staff E, Registered Nurse (RN), reported the hospice aide does perform transfers with the hoyer lift. The nurse is usually present so they tag team the transfer and that is why the nurse did not assign the hoyer lift transfers as a task. The aide did inform the nurse today regarding the task not being assigned and the nurse is working on adding the task to the care plan. The Hospice Aide Care Plan, lacked identification of the task of hoyer lift transfers to make the care plan specific and individualized for the patient. 2. Patient #3 had a hospice admission date of 3/2/22 and received hospice services while residing in a nursing home. See L0545 for evidence for Patient #3. An interim physician order entered by Staff E, RN, dated 3/15/22, included a hospice aide assignment with directions for the hospice aide to assist with feeding the patient, offer fluids every 2 hours and with each meal and offer snacks between meals. The assignment also included the following tasks: provide incontinence care as needed if soiled, emotional support (patient likes to be read to), transfer using 2 people, set up food tray, bed bath on Tuesdays and Thursdays, seated shower on Monday, Wednesday and Friday, shampoo Wednesday during shower, apply lotion to all extremities, assist with dressing patient in layers, assist with undressing patient, comb or brush hair, assist with brushing teeth using a soft tooth brush and toothpaste, clean and file nails once a week, change bed linens if soiled, empty trash, make the bed, observe fall precautions and observe standard universal precautions. The hospice RN failed to create a written assignment for the hospice aide to follow prior to 3/15/22. 3. Patient #4 had a hospice admission date of 11/9/2020 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: The POCs, dated 1/3/22 to 3/3/22 and 3/4/22 to 5/2/22, included orders for hospice aide services 3 times per week and directions for the hospice aide to complete the following task: may transport with motorized wheel chair outside to patio per patient request and whether permitting. The POC identified a Hoyer lift as medical equipment used by the patient, but the hospice aide assignment failed to include instructions for the hospice aide to use a mechanical lift with transfers. On 3/16/22 at 12:49 PM, during an interview, Staff F, Hospice Aide, reported she has helped facility staff to transfer the patient a couple times from the bed to the patient's recliner using the Hoyer lift. On 3/16/22 at 12:57 PM, during an interview, Staff H, RN, reported her awareness of the hospice aides occasionally transferring the patient with facility staff using the Hoyer lift. She confirmed the Hoyer lift was not on the hospice aide assignment and she voiced a plan to add this to the hospice aide assignment "right now". The hospice aide assignment failed to include directions to the hospice aide to assist the patient with transfers and to use a Hoyer lift. The Administrator and Clinical Manager received the above findings. On 3/21/22 at 1:35 PM, during an interview, the Administrator reported hospice staff were unable to find further information.

Based on clinical record review, hospice policy review, nursing home staff interview and hospice staff interview, the hospice failed to ensure hospice aides provided services as ordered by the Interdisciplinary Team according to an individualized plan of care for 4 of 10 sampled patients who received hospice aide services (Patients #4, #9, #10 and #12). The hospice reported a total of 49 patients received hospice aide services at the time of the survey. Failure to provide hospice aide services as ordered on the plan of care increased the risk that hospice patients' personal care needs were not met. Findings include: According to the hospice policy, titled Hospice Aide Services, dated 10/2020, hospice aide assignments, plan of care, and interventions will be documented and included in the patient's clinical record. Hospice aides will document care provided in accordance with the hospice aide assignment. During an interview on 3/15/22 at 2:39 PM, with the Clinical Manager, reported the registered nurse (RN) creates the hospice aide care plan, the care plan is reviewed every 2 weeks, the hospice aide should document if the task was completed or not completed and if not completed the aide should notify the RN. If the aide is requested to complete a task not on the care plan, the aide would call the RN. 1. Patient #9 had a hospice admission date of 2/4/2022 and received hospice services while residing in a private home residence. Clinical record review revealed: a. The Plan of Care (POC), dated 2/4/2022 to 5/4/2022, included IDG orders for skilled nursing and aide services. b. The aide care plan included RN instructions to the aide to complete the tasks of a bed bath on Monday, Wednesday and Thursday and a seated shower on Tuesday and Friday. c. The hospice aide visit note, dated 2/15/22 (a Tuesday), documented the shower was not performed and the reason not performed as the patient showers on Mondays and Fridays. The aide failed to perform tasks as assigned on the aide care plan. d. The hospice aide visit note, dated 2/22/22 (a Tuesday), documented the shower was not performed and the reason not performed as bedbath. The aide failed to perform tasks as assigned on the aide care plan. e. The hospice aide visit note, dated 2/24/22 (a Friday), documented the shower was not performed and the reason not performed as bedbath. The aide failed to perform tasks as assigned on the aide care plan. The aide visit notes lacked documentation of notification to the registered nurse of the inability to follow the plan of care. 2. Patient #4 had a hospice admission date of 11/9/2020 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 1/3/22 to 3/3/22, included orders for hospice aide services 3 times per week and the following assignment of tasks: place call light within reach, 2 female caregivers with all cares in the room, coordinate cares with the facility staff, bed bath per patient request, wash between fingers and toes with the visit, call the RN if skin breakdown, check and change if soiled, provide companionship during visits, set up tray and assist with feeding, offer fluids every 2 hours and with meals, may transport with motorized wheel chair outside to patio per patient request and whether permitting, brush teeth, comb/brush hair, apply make up per patient preference, empty the trash, tidy the room, apply barrier cream with brief change, clean fingernails and file if long. An Interdisciplinary Group (IDG) meeting, dated 1/26/22, included instructions for the hospice aide to complete the task of encouraging use and assisting patient with use of the incentive spirometer for 10 repetitions every 2 hours while awake. b. The hospice aide visit note, dated 2/23/22, included documentation the hospice aide did not perform the task of encouraging use and assisting patient with the use of the incentive spirometer. The visit note lacked a reason to explain why the hospice aide failed to complete the assigned task and lacked any contact with the patient's nurse to discuss the uncompleted task. c. The hospice aide visit note, dated 2/23/22 at 12:05 PM, included documentation the hospice aide did not perform the tasks of encouraging use and assisting patient with the use of the incentive spirometer and providing feeding assistance. The visit note lacked a reason to explain why the hospice aide failed to complete the assigned task and lacked any contact with the patient's nurse to discuss the uncompleted task. 3. Patient #10 had a hospice admission date of 5/27/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 1/22/22 to 3/22/22, included IDG orders for hospice aide services 5 times per week. The POC included orders for the hospice aide to complete the following tasks: provide incontinence care as needed if soiled, passive range of motion to all extremities, transfer using 2 people with the Hoyer lift, place call bell within reach, set up tray and assist feed patient, seated shower, shampoo hair, apply lotion to all extremities, assist with dressing and undressing, comb or brush hair, brush teeth, assist with shaving razor on chin hair, clean and file fingernails, report skin breakdown or redness to registered nurse (RN), observe fall precautions, observe standard universal precautions, empty trash and make the bed. b. The hospice aide visit notes, dated 1/24 through 1/26, 1/28, 1/31 through 2/4, 2/7 through 2/10, 2/14 through 2/18, 2/21 to 2/23, 2/25, 3/1, 3/3, 3/4, 3/7, 3/8 and 3/10/22, all included documentation by Staff G, Hospice Aide, that the caregiver completed all of the tasks with the exception of a shower and shampoo. Staff G, Hospice Aide, documented he did not perform the assigned tasks of a shower and shampoo and failed to document a reason to explain why the hospice aide failed to complete the assigned tasks. c. The hospice aide visit notes, dated 2/24, 2/28 and 3/11/22, all included documentation by Staff G, Hospice Aide, that the caregiver completed all of the tasks with the exception of a shampoo. Staff G, Hospice Aide, documented he did not perform the assigned task of shampooing the patient's hair and failed to document a reason to explain why the hospice aide failed to complete the assigned task. d. The hospice aide visit note, dated 3/2/22, included documentation by Staff G, Hospice Aide, that the caregiver completed all of the tasks with the exception of a shower, teeth brushing and shampoo. Staff G, Hospice Aide, documented he did not perform the assigned tasks of a shower, teeth brush and shampoo and failed to document a reason to explain why the hospice aide failed to complete the assigned tasks. e. The hospice aide visit note, dated 3/9/22, included documentation by Staff G, Hospice Aide, that the caregiver completed all of the tasks with the exception of a shower. Staff G, Hospice Aide, documented he did not perform the assigned task of a shower and failed to document a reason to explain why the hospice aide failed to complete the assigned task. On 3/17/22 at 9:07 AM, during an interview, Staff G, Hospice Aide, reported he did not shower the patient, because the nursing home staff had already done this prior to his visit. When asked if this meant every day, he reported the nursing home staff gave the patient a shower every day. He reported he did all of the other tasks. He did not know why the documentation showed that the caregiver (nursing home staff) provided all of the cares. He explained he had been assisting to the feed the patient, shave the patient and change the patient's briefs. On 3/17/22 at 12:45 PM, during an interview, the Director of Nursing for the patient's nursing home reported the nursing home staff only provided the patient with a shower 2 times per week. The hospice was supposed to provide bathing for anything more than the 2 times per week the nursing staff provided. 4. Patient #12 had a hospice admission date of 10/26/21, received hospice services while residing in a residential care facility and discharged from hospice services on 1/21/22. Review of the clinical record revealed the following: a. The POC, dated 10/26/21 to 1/23/22, included IDG orders for skilled nursing, spiritual counseling care and social worker services. b. An IDG meeting, dated 12/1/21, included IDG orders for hospice aide services 3 times per week from 11/26/21 to 1/23/22. The IDG meeting included the following assigned tasks for the hospice aide to complete: patient can shower or use the spa tub bath with assist, file nails per patient request, change brief if soiled, provide emotional support and companionship, encourage independent self care, assist with dressing and undressing the patient, patient wears an alert pendant at all times during shift, observe safety and fall precautions and observe standard universal precautions. c. A hospice aide visit completed by Staff G, Hospice Aide, dated 12/16/21, included documentation by Staff G, Hospice Aide, that the caregiver completed all of the tasks with the exception of a shower and filing of the patient's nails. Staff G, Hospice Aide, documented he did not perform the assigned tasks of a shower and filing of the patient's nails and failed to document a reason to explain why the hospice aide failed to complete the assigned tasks. Hospice aide staff failed to provide care according to the POC. The Administrator and Clinical Manager received the above information. On 3/21/22 at 1:35 PM, during an interview, the Administrator reported hospice staff were unable to find further information.

Based on clinical record review, hospice policy review, nursing home staff interview and hospice staff interview, the hospice failed to ensure clinical records contained pertinent, up-to-date and complete information in a timely manner and failed to ensure correction of errors were made in the clinical record according to agency policy for 4 of 13 sampled patients (#3, #5, #10 and #12). Failure to maintain accurate clinical records with current patient information increased the risk that hospice staff provided services without up to date information related to the patient's condition, and decreased the ability of hospice staff to communicate effectively in order to coordinate patient care. Findings include: According to the hospice policy, titled Clinical/Service Data Collection, dated 10/2021, entries to the clinical/service record will be clear, concise and specific statements of fact. The clinical note will include what care/service was provided, treatment and/or invasive procedures performed and patient response to treatment and/or procedures. During an interview on 3/15/22 at 2:39 PM, with the Clinical Manager, the registered nurse (RN) creates the hospice aide care plan, the care plan is reviewed every 2 weeks, the hospice aide should document if the task was completed or not completed and if not completed the aide should notify the RN. If the aide is requested to complete a task not on the care plan, the aide would call the RN. 1. Patient #5 had a hospice admission date of 7/18/2021 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plans Of Care, dated 12/15/21 to 2/12/22 and 2/13/22 to 4/13/22, included IDG orders for skilled nursing and hospice aide services and documented activities permitted as transfer bed to chair, wheelchair, and hoyer lift. b. The Hospice Aide Care Plan, for the certification periods, 12/15/21 to 2/12/22 and 2/13/22 to 4/13/22, included the following tasks for the home care aide: place call light within reach, change brief if soiled, measure and report urine output each shift and as needed, suprapubic catheter care with bathing, set up tray and assist feeding the patient, offer fluids every 2 hours and with meals, apply lotion to all extremities, assist with dressing and undressing the patient, apply heel protectors, provide back rub, and clean and file nails as directed by caregiver. Interview on 3/16/22 at 11:56 AM with Staff J, Hospice Aide, reported the aide does transfer patient with the hoyer lift and has used the hoyer lift since the patient's admission to the agency in July of 2021. The hospice aide notes, dated 1/11, 1/18, 1/20, 1/25, 1/27, 1/31, 2/2, 2/7, 2/9, 2/11, 2/14, 2/17, 2/19, 2/20, 2/21, 2/22, 2/24, 2/28, 3/2, 3/7, 3/9, and 3/11/22, lacked documentation of the aide's performance of the task of the hoyer lift or notification of nurse to perform the unassigned task. 2. Patient #3 had a hospice admission date of 3/2/22 and received hospice services while residing in a nursing home. Review of the clinical record on 3/15/22 revealed the following: a. The Plan of Care (POC), dated 3/2/22 to 5/30/22, identified a diagnosis of Alzheimer's and included Interdisciplinary Group (IDG) orders for home health aide services 1 time for one week, 3 times a week for one week and one time per week for a week. b. The clinical record lacked documentation of a hospice aide assignment. c. The clinical record included documentation of hospice aide visit notes completed by Staff J, Hospice Aide, dated 3/4, 3/7, 3/9, 3/11, 3/12, 3/13 and 3/14/22. The hospice aide visit notes identified the hospice aide completed a visit, but lacked any documentation on what interventions the hospice aide completed. On 3/15/22 at 12:43 PM, during an interview, Staff E, RN, explained there was a care plan/assignment for the hospice aide in her computer, and explained there was a difference between what was in the mobile application of the computer compared to the office application viewable in the electronic system. An interim physician order entered by Staff E, RN, dated 3/15/22, included a hospice aide assignment with directions for the hospice aide to assist with feeding the patient, offer fluids every 2 hours and with each meal and offer snacks between meals. The assignment also included the following tasks: provide incontinence care as needed if soiled, emotional support (patient likes to be read to), transfer using 2 people, set up food tray, bed bath on Tuesdays and Thursdays, seated shower on Monday, Wednesday and Friday, shampoo Wednesday during shower, apply lotion to all extremities, assist with dressing patient in layers, assist with undressing patient, comb or brush hair, assist with brushing teeth using a soft tooth brush and toothpaste, clean and file nails once a week, change bed linens if soiled, empty trash, make the bed, observe fall precautions and observe standard universal precautions. On 3/16/22 at 10:20 AM, during an interview, the Clinical Manager reported the electronic system did not show evidence of a hospice aide assignment until 3/15/22. She explained if the nurse had put something in the mobile application, it would not be viewable to other staff, including the hospice aide, until the information was synced to office portion of the electronic record. On 3/16/22 at 10:57 AM, during an interview, Staff J, Hospice Aide, explained she had only been cuing the patient on taking bites during each of the visits. She reported she had not been doing anything else. When asked how she knew what to do without a written assignment prior to 3/15/22, she explained the nurse told her verbally what to do. She reported talking with the nurse daily. She further explained Staff E, RN, suggested on Friday of last week(3/11/22) to give the patient a whirlpool bath, and she gave the patient a whirlpool bath on Monday (3/14/22). The hospice aide failed to document interventions completed during each of the hospice aide visits. 3. Patient #10 had a hospice admission date of 5/27/21 and received hospice services while residing in a nursing home. See L0626 for evidence for Patient #10. The hospice aide failed to accurately document interventions completed by the hospice aide rather than the caregiver (facility staff). 4. Patient #12 had a hospice admission date of 10/26/21, received hospice services while residing in a residential care facility and discharged from hospice services on 1/21/22. Review of the clinical record revealed the following: a. The POC, dated 10/26/21 to 1/23/22, included IDG orders for skilled nursing, spiritual counseling care and social worker services. b. An IDG meeting, dated 12/1/21, included IDG orders for hospice aide services 3 times per week from 11/26/21 to 1/23/22. The IDG meeting included the following assigned tasks for the hospice aide to complete: patient can shower or use the spa tub bath with assist, file nails per patient request, change brief if soiled, provide emotional support and companionship, encourage independent self care, assist with dressing and undressing the patient, patient wears an alert pendant at all times during shift, observe safety and fall precautions and observe standard universal precautions. c. A hospice aide visit completed by Staff G, Hospice Aide, dated 12/16/21, included documentation by Staff G, Hospice Aide, that the caregiver completed all of the tasks with the exception of a shower and filing of the patient's nails. Staff G, Hospice Aide, documented he did not perform the assigned tasks of a shower and filing of the patient's nails. The hospice aide documented the "caregiver" completed tasks completed by the hospice aide and failed to accurately document interventions. The Administrator and Clinical Manager received the above information. On 3/21/22 at 1:35 PM, during an interview, the Administrator reported hospice staff were unable to find further information.

Based on clinical record review, policy review and staff interview, the hospice failed to ensure patient clinical records included a physician order for all treatments for 3 of 5 sampled patients with wounds (Patients #8, #10 and #11). Failure to have physician order for all medications and treatments created the potential for patients to receive incorrect or ineffective treatment to meet assessed needs. Findings include: Review of the hospice's policy, titled Assembly of Clinical Record, dated 10/2021, revealed the clinical record content will include physician orders, plan of care/treatment, verbal orders and pharmaceutical orders. Review of the hospice's policy, titled Skin Management, dated 02/2022, revealed wound care treatment to be completed as ordered by physician/provider. 1. Patient #8 had a a hospice admission date of 1/7/22 and received hospice services while residing in a private home. Clinical record review revealed the following: a. The Plan of Care, dated 1/7/22 to 4/6/22, included physician orders for oxygen safety, assess and document patient/caregiver understanding of identified safety risks and compliance with suggested interventions. The orders failed to identify the oxygen liter flow, route of administration and frequency for use of oxygen. b. The IDG meeting notes, dated 1/12/22, 1/26/22, 2/9/22, 2/23/22 and 3/9/22, included documentation of oxygen safety but failed to include order for oxygen liter flow, route of administration and frequency for use of oxygen. c. Skilled nurse visit note, dated 2/28/22, included documentation the patient spouse was applying Calmoseptine and Vaseline to left buttock stage 2 pressure ulcer. Skilled nurse called physician to update on wound and obtain verbal order for topical treatment. d. Patient note, dated 3/1/22, included documentation of return call from physician office and verbal order received for spouse or hospice nurse to apply Calmoseptine and Vaseline to pressure ulcer twice daily until healed. The clinical record lacked documentation of a physician order for the Calmoseptine and Vaseline for wound care. 2. Patient #11 had a a hospice admission date of 11/10/21, a revocation date of 12/14/21 and received hospice services while residing in a private home. Clinical record review revealed the following: a. The IDG meeting note, dated 12/1/21, included documentation of podiatry consult with hospice assist with first appointment and skin care focused on prevention of breakdown. b. The skilled nursing visit note, dated 12/9/21, included documentation podiatry appointment yesterday and to betadine toes daily, completed at this visit. The clinical record lacked documentation of a physician order directing the nurse to apply betadine to toes. 3. Patient #10 had a hospice admission date of 5/27/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 1/22/22 to 3/22/22, included Interdisciplinary Group (IDG) orders for skilled nursing services. b. A skilled nursing visit note, dated 2/11/22, included documentation which identified the patient had fallen off the bed. The patient had a skin tear to the right forearm. The nurse documented the physician ordered the following wound care treatment: cleanse with wound cleanser, apply Adaptic, cover with Telfa, cover with an abdominal (ABD) pad and Kerlix dressing and tape, change Adaptic dressing every 7 days and outer dressing per physician orders. c. Review of the hospice clinical record on 3/16/22 revealed a lack of documentation of wound care orders for the right forearm. The Administrator and Clinical Manager received the above information. On 3/21/22 at 1:35 PM, during an interview, the Administrator reported hospice staff were unable to find further information.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure all entries completed in the patient electronic clinical records were signed and dated for 4 of 8 sampled patients with massage or music therapy (Patients #2, #4, #10 and #12). Failure to ensure all clinical record documentation included accurate information and were completed timely may result in ineffectively coordinated patient care. Findings include: The hospice policy, titled Clinical/Service Data Collection, dated 10/2021, identified the clinical/service note will include the date the service was provided (month, day, year) and signature of clinician/technician and his/her credentials. 1. Patient #2 had a hospice admission date of 10/19/21 and received hospice services while residing in a private home. Clinical record review revealed the following: a. Massage therapy paper visit notes, dated 1/11/22, 2/1/22, 2/15/22, 3/1/22 and 3/8/22, lacked therapist signature and credentials. b. Music therapy electronic visit notes, dated 1/13/22 and 3/9/22, included an electronic signature that included the therapist name and date but lacked therapist credentials. 2. Patient #4 had a hospice admission date of 11/9/2020 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POCs, dated 1/3/22 to 3/3/22 and 3/4/22 to 5/2/22, included IDG orders, interventions and goals for skilled nursing, hospice aide, spiritual counseling care (SCC), social worker and music therapy services. b. The IDG meetings, dated 12/29/21 and 1/12, 1/26, 2/9, 2/23 and 3/9/22, identified the hospice provided massage services. c. Review of clinical record identified visit notes for massage therapy services, dated 1/6, 1/20, 1/27, 2/3, 2/10, 2/14, 2/23, 3/3 and 3/9/22. The visit notes lacked a signature and title of the person completing the visit note and a date for when the person completed the visit note documentation. 3. Patient #10 had a hospice admission date of 5/27/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 1/22/22 to 3/22/22, included IDG orders for hospice aide services 5 times per week. b. The hospice aide visit notes, dated 1/24 through 1/26, 1/28, 1/31 through 2/4, 2/7 through 2/10, 2/14 through 2/18, 2/21 through 2/25, 2/28 through 3/4 and 3/7 through 3/11/22, all included a signature of documentation of completion and a date, but lacked a title of the person completing the notes. 4. Patient #12 had a hospice admission date of 10/26/21, received hospice services while residing in a residential care facility and discharged from hospice services on 1/21/22. Review of the clinical record revealed the following: a. The POC, dated 10/26/21 to 1/23/22, included IDG orders for skilled nursing, spiritual counseling care and social worker services. b. An IDG meeting, dated 12/1/21, included IDG orders for hospice aide services 3 times per week from 11/26/21 to 1/23/22. c. A hospice aide visit note, dated 12/16/21, included a signature of documentation of completion and a date, but lacked a title of the person completing the note. The Administrator and Clinical Manager received the above information. On 3/21/22 at 1:35 PM, during an interview, the Administrator reported hospice staff were unable to find further information.

Based on clinical record review, the hospice interdisciplinary group failed to document the assessment of the patient and/or caregiver's ability to safely and accurately administer medications for 8 of 9 sampled patients who received hospice services while living in a private home residence (Patients #1, #2, #6, #7, #8, #9, #12 and #13). The hospice reported a census of 57 patients at the time of the survey, 23 of which lived in a private residence. Failure to ensure the Interdisciplinary Group (IDG) evaluated either the patient and/or family caregiver's ability to safely and accurately administer medications decreased the ability of the hospice to ensure the safe effective delivery of ordered medications. Findings include: 1. Patient #1 had a hospice admission date of 6/7/19 and received hospice services while residing in a private home residence. The Plans of Care (POCs), dated 6/7/19 to 9/4/19, 9/24/21 to 11/22/21, 11/23/21 to 1/21/22, and 1/22/22 to 3/22/22, included orders for medications and IDG orders for skilled nursing, social work, clergy and hospice aide services. The POC and the IDG meeting to updates the POC, dated 1/12/22, 1/26/22, 2/9/22, 2/23/22, and 3/9/22, lacked any documentation which identified whether or not the IDG members determined the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in the patient's home. 2. Patient #6 had a hospice admission date of 1/17/2022 and received hospice services while residing in a private home residence. The POC, dated 1/17/22 to 4/16/22, included orders for medications and included IDG orders for skilled nursing, social work and hospice aide services. The POC and the IDG meeting to updates the POC, dated 1/26/22, 2/9/22, 2/23/22, and 3/9/22, lacked any documentation which identified whether or not the IDG members determined the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in the patient's home. 3. Patient #9 had a hospice admission date of 2/4/2022 and received hospice services while residing in an assisted living facility. The POC, dated 2/4/22 to 5/4/22, included orders for medications and included IDG orders for skilled nursing, hospice aide, spiritual care, and music therapy services. The POC and the IDG meeting to updates the POC, dated 2/16/22 and 3/2/22, lacked any documentation which identified whether or not the IDG members determined the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in the patient's home. 4. Patient #13 had a hospice admission date of 11/18/21, received hospice services while residing in a private home residence and died at home on 1/1/22. The POC, dated 11/18/21 to 2/15/22, included orders for medications and included IDG orders for skilled nursing, social work, spiritual care, and hospice aide services. The POC and the IDG meeting to update the POC, dated 11/24/21, 12/8/21, 12/22/21, and 1/5/22, lacked any documentation which identified whether or not the IDG members determined the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in the patient's home. 5. Patient #12 had a hospice admission date of 10/26/21, received hospice services while residing in a residential care facility and discharged from hospice services on 1/21/22. Review of the clinical record revealed the following: a. The POC, dated 10/26/21 to 1/23/22, included orders for medications, but lacked IDG determination of the patient's or family's ability to safely administer medications in the patient's home or if the facility was administering the patient's medications. b. The initial IDG meeting, dated 11/3/21, failed to include any documentation regarding IDG determination of the patient's or family's ability to safely administer medications in the patient's home or if the facility was administering the patient's medications. 6. Patient #2 had a hospice admission date of 10/19/21 and received hospice services while residing in a private home. Clinical record review revealed the following: a. The initial Plan of Care (POC), dated 10/19/21 to 1/16/22, included physician orders for medications. The POC did not include any information which identify the IDG determined the ability of the patient and/or family to safely administer medications to the patient in his/her home. b. The initial IDG meeting note, dated 10/20/21, lacked documentation which identified the IDG determined the ability of the patient and/or family to safely administer medications to the patient in his/her home. 7. Patient #7 was admitted to hospice on 8/18/21 and received services while residing in a private home. Clinical record review revealed the following: a. The initial POC, dated 11/16/21 to 2/13/22, included physician orders for medications. The POC did not include any information which identify the IDG determined the ability of the patient and/or family to safely administer medications to the patient in his/her home. b. The initial IDG meeting note, dated 8/25/21, lacked documentation which identified the IDG determined the ability of the patient and/or family to safely administer medications to the patient in his/her home. 8. Patient #8 was admitted to hospice on 1/7/22 and received services while residing in a private home. Clinical record review revealed the following: a. The initial POC, dated 1/7/22 to 4/6/22, included physician orders for medications. The POC did not include any information which identify the IDG determined the ability of the patient and/or family to safely administer medications to the patient in his/her home. b. The initial IDG meeting note, dated 1/12/22, lacked documentation which identified the IDG determined the ability of the patient and/or family to safely administer medications to the patient in his/her home. The above findings were reviewed with the Administrator, Clinical Manager, and Quality Coordinator. Hospice staff provided no further information prior to the end of the survey. On 3/21/22 at 1:35 PM, during an interview, the Administrator reported hospice staff were unable to find further information.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to maintain documentation in the patient clinical records as evidence that patients received a copy of the hospice policy concerning the disposition of controlled medications and hospice staff discussed this policy with the patient/caregiver for 2 of 7 sampled patients (Patients #8 and #13) who received routine home care while living in a private home and had physician ordered controlled medication. Failure to ensure patients and/or caregivers received adequate education on the use and disposition of controlled (medication whose manufacture, possession and use is controlled by the government) increased the risk of inappropriate use of narcotics and other controlled substances by individuals other than the patient for whom the medication was prescribed. Findings include: Review of the hospice policy, titled Home Use and Disposal of Controlled Substances, dated 10/2020, identified the admitting nurse/case manager will provide a copy of the written policies and procedures on the management and disposal of controlled drugs to the patient/representative and family. The admitting nurse/case manager will verbally discuss the policy with the patient/representative and family/caregiver in a language and manner that they understand to ensure the safe use and disposal of controlled drugs. The admitting nurse/case manager will document in the clinical record that the patient and family/caregiver were given the written policies and procedures for managing controlled drugs and discussed the disposal of medications and took responsibility to do so. 1. Patient #8 was admitted to hospice on 1/7/22 and received services while residing in a private home. Clinical record review revealed the following: a. The Plan of Care, dated 1/7/22 to 4/6/22, included physician orders for Alprazolam (anti-anxiety med) and morphine (pain med), controlled medications. b. The initial comprehensive assessment visit note, dated 1/7/22, lacked any documentation the nurse provided and discussed information and education on the disposal of controlled medications with the patient/caregiver. 2. Patient #13 had a hospice admission date of 11/18/2021, received hospice services while residing in a private home residence and died at home on 1/1/2022. Clinical record review revealed: The Plans of Care (POCs), dated 11/18/21 to 2/15/22, included IDG orders for skilled nursing services. The POC, dated 11/18/21 to 2/15/22, included orders for Morphine concentrate 20 milligrams (mg) per 1 milliliter (ml) and orders to administer 0.25 ml every 4 hours as needed for pain or problems breathing started on 12/4/2021. The clinical record lacked orders for a controlled medication prior to the patient starting the Morphine. The clinical record included documentation of skilled nursing visits on 12/4/22, 12/6/22, 12/16/22, 12/17/22, 12/24/22, 12/27/22, and 12/30/22. The visit notes lacked documentation the nurse provided the written policy and education on the disposal of controlled medications to the patient/caregiver. The above findings were reviewed with the Hospice Administrator and Hospice Clinical Manager. On 3/21/22 at 1:35 PM, during an interview, the Administrator reported hospice staff were unable to find further information.

Based on clinical record review and hospice policy review, the hospice failed to delineate on the hospice plan of care responsibilities between the hospice and long term care (nursing home) staff for 2 of 4 sampled patients receiving hospice services while residing in a nursing home (Patients #3 and #5). The hospice reported a total of 34 patients received routine hospice services while residing in a nursing home. Failure to delineate which provider had specific responsibilities for patient care to patients residing in a nursing home increased the risk that patients failed to receive adequate care and treatments according to physician's orders and the plan of care. Findings include: According to the hospice policy, titled Care/Service Coordination, dated 10/2020, identified timely and ongoing communication is the responsibility of each team member and will be appropriate to the needs and abilities of the patient, and relevant to the care/service provided. The clinician/technician will be responsible for facilitating communications about changes in the patients status among the assigned team members. The assigned clinician/technician will be qualified through education, training and/or experience and will know the scope of care/service that can be provided by various team members. The case manager will be responsible for cooperative care planning in order to assure that goals, actions, and the interrelationship of services is not duplicated and to minimize the potential for missed or conflicting services. 1. Patient #5 had a hospice admission date of 7/18/2021 and received hospice services while residing in a nursing home. a. The Plans of Care (POC), dated 12/15/21 to 2/12/22, and 2/13/22 to 4/13/22 included IDG orders for skilled nursing, hospice aide, social worker, spiritual care and music therapy services. b. The POCs, dated 12/15/21 to 2/12/22, and 2/13/22 to 4/13/22 included documentation the facility staff was responsible for changing the patients 22 french catheter every 28 to 31 days and as needed and change the drainage bag every 2 weeks and IDG updates to the POC failed to delineate any additional responsibilities (including medication administration) of the nursing home facility in order to determine which services the hospice planned to provide and which services the facility was responsible to provide. 2. Patient #3 had a hospice admission date of 3/2/22 and received hospice services while residing in a nursing home. Review of the clinical record on revealed the following: The Plan of Care (POC), dated 3/2/22 to 5/30/22, included Interdisciplinary Group (IDG) orders for skilled nursing, hospice aide, spiritual counseling care, social worker and music therapy services. The POCs failed to delineate responsibility for care and services between the hospice and nursing home. The patient took medications, but the POC failed to identify which entity was responsible for the administration of the patient's medications. The POC included orders for home health aide services, but failed to identify what interventions the hospice aide would be responsible for completing. The Administrator and Clinical Manager received the above information. On 3/21/22 at 1:35 PM, during an interview, the Administrator reported hospice staff were unable to find further information.

Based on clinical record review, long term care (nursing home) medication and treatment administration records, hospice policy review, nursing home staff interview and hospice staff interview, the hospice failed to ensure hospice staff provided overall coordination of the hospice care with the nursing home for 2 of 2 sampled patients (Patient #3 and #10) with an on-site visit to the patient's nursing home residence. Failure to ensure the hospice staff provided overall coordination of patient care with the nursing home placed the patient at risk for not receiving care and/or treatment according to the hospice philosophy. Findings Include: According to the hospice policy, titled Care/Service Coordination, dated 10/2020, identified timely and ongoing communication is the responsibility of each team member and will be appropriate to the needs and abilities of the patient, and relevant to the care/service provided. The clinician/technician will be responsible for facilitating communications about changes in the patients status among the assigned team members. The assigned clinician/technician will be qualified through education, training and/or experience and will know the scope of care/service that can be provided by various team members. The case manager will be responsible for cooperative care planning in order to assure that goals, actions, and the interrelationship of services is not duplicated and to minimize the potential for missed or conflicting services. According to the hospice policy, titled, The Plan of Care, dated 10/2020, the plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, by the Interdisciplinary Group (IDG), with input from the attending physician, the patient, and the family/caregiver, based on ongoing comprehensive assessments of the patient and family/caregiver. Review of the plan of care will be documented in the clinical record. Revision dates will be noted on the plan of care. 1. Patient #3 had a hospice admission date of 3/2/22 and received hospice services while residing in a nursing home. Review of the clinical record on revealed the following: The Plan of Care (POC), dated 3/2/22 to 5/30/22, included Interdisciplinary Group (IDG) orders for skilled nursing, hospice aide, spiritual counseling care (SCC), social worker and music therapy services. The POC included physician orders for medications. Review of the patient's nursing home medication orders, titled Order Summary Report, dated 3/15/22, and the hospice's document, titled Medication Profile, which contained the hospice's current medication orders, identified the following medication discrepancies: a. The hospice's Medication Profile included an order for Acetaminophen 325 milligrams (mg) tablets, 2 tabs by mouth every 6 hours as needed for pain/fever and a start date of 3/8/22. The nursing home's Order Summary Report lacked an order for the medication. b. The hospice's Medication Profile included an order for Eliquis 2.5 mg 1 tab by mouth twice per day and a start date of 3/8/22. The nursing home's Order Summary Report had an order for Eliquis 5 mg 1 tab twice per day and a start date of 1/11/22. c. The hospice's Medication Profile included an order for Ibuprofen 200 mg tablets, 2 tablets every 4 hours as needed and Ibuprofen 400 mg, 2 tablets every 6 hours as needed for pain both with a start date of 3/8/22. The nursing home's Order Summary Report contained one order for Ibuprofen 400 mg, give 1 tablet by mouth every 4 hours as needed for pain and a start date of 3/8/22. d. The nursing home's Order Summary Report included an order for Polyethylene Glycol Powder 17 grams by mouth one time per day, mix in 8 ounces of water and a start date of 3/9/22. The hospice's Medication Profile lacked an order for the medication. e. The nursing home's Order Summary Report included an order for Milk of Magnesia suspension 1200 mg per milliliter (ml), give 30 ml by mouth every 24 hours as needed for constipation and a start date of 3/8/22. The hospice's Medication Profile lacked an order for the medication. The hospice nurse failed to ensure the coordination of medications between the hospice and the nursing home. 2. Patient #10 had a hospice admission date of 5/27/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 1/22/22 to 3/22/22, included IDG orders for skilled nursing services, hospice aide services, music therapy, social work and SCC services. The POC included physician orders for medications. Review of the patient's nursing home medication orders, titled Medication Administration Record (MAR), dated March 2022, and the hospice's document, titled Medication Profile, which contained the hospice's current medication orders, identified the following medication discrepancy: The nursing home's MAR included an order for Milk of Magnesia suspension, give 30 ml orally as needed for constipation on day 3 if no bowel movement and a start date of 11/1/19. The hospice's Medication Profile lacked an order for the medication. b. The POC, dated 1/22/22 to 3/22/22, included IDG orders for hospice aide services 5 times per week. The POC included orders for the hospice aide to complete the following tasks: provide incontinence care as needed if soiled, passive range of motion to all extremities, transfer using 2 people with the Hoyer lift, place call bell within reach, set up tray and assist feed patient, seated shower, shampoo hair, apply lotion to all extremities, assist with dressing and undressing, comb or brush hair, brush teeth, assist with shaving razor on chin hair, clean and file fingernails, report skin breakdown or redness to registered nurse (RN), observe fall precautions, observe standard universal precautions, empty trash and make the bed. 1) The hospice aide visit notes, dated 1/24 through 1/26, 1/28, 1/31 through 2/4, 2/7 through 2/10, 2/14 through 2/18, 2/21 to 2/23, 2/25, 3/1, 3/3, 3/4, 3/7, 3/8 and 3/10/22, all included documentation by Staff G, Hospice Aide, that the caregiver completed all of the tasks with the exception of a shower and shampoo. Staff G, Hospice Aide, documented he did not perform the assigned tasks of a shower and shampoo and failed to document a reason to explain why the hospice aide failed to complete the assigned tasks. 2) The hospice aide visit notes, dated 2/24, 2/28 and 3/11/22, all included documentation by Staff G, Hospice Aide, that the caregiver completed all of the tasks with the exception of a shampoo. Staff G, Hospice Aide, documented he did not perform the assigned task of shampooing the patient's hair and failed to document a reason to explain why the hospice aide failed to complete the assigned task. 3) The hospice aide visit note, dated 3/2/22, included documentation by Staff G, Hospice Aide, that the caregiver completed all of the tasks with the exception of a shower, teeth brushing and shampoo. Staff G, Hospice Aide, documented he did not perform the assigned tasks of a shower, teeth brush and shampoo and failed to document a reason to explain why the hospice aide failed to complete the assigned tasks. 4) The hospice aide visit note, dated 3/9/22, included documentation by Staff G, Hospice Aide, that the caregiver completed all of the tasks with the exception of a shower. Staff G, Hospice Aide, documented he did not perform the assigned task of a shower and failed to document a reason to explain why the hospice aide failed to complete the assigned task. On 3/16/22 at 8:26 AM, during an interview, the Director of Nursing for the patient's nursing home reported the hospice nurse did communicate with the nursing home staff when the hospice admitted a new patient and the hospice RN communicated changes and orders, however; hospice staff did not participate in the nursing home care planning process except through the family. On 3/17/22 at 9:07 AM, during an interview, Staff G, Hospice Aide, reported he did not shower the patient, because the nursing home staff had already done this prior to his visit. When asked if this meant every day, he reported the nursing home staff gave the patient a shower every day. He reported he did all of the other tasks. He did not know why the documentation showed that the caregiver (nursing home staff) provided all of the cares. He explained he had been assisting to the feed the patient, shave the patient and change the patient's briefs. On 3/17/22 at 12:45 PM, during an interview, the Director of Nursing for the patient's nursing home reported the nursing home staff only provided the patient with a shower 2 times per week. The hospice was supposed to provide bathing for anything more than the 2 times per week the nursing staff provided. The hospice RN failed to ensure the overall coordination of care, services and medications between the hospice and the nursing home. The Administrator and Clinical Manager received the above information. On 3/21/22 at 1:35 PM, during an interview, the Administrator reported hospice staff were unable to find further information.

Based on hospice clinical record review, hospice policy review, long term care (nursing home) clinical record review, nursing home staff and hospice staff interview, the hospice failed to ensure the nursing home where hospice patients resided received all required hospice documentation for 2 of 2 sampled patients who received an on-site record review at the facility (Patients #3 and #10). Failure to communicate hospice information to nursing home staff placed patients at risk to not receiving necessary care and services. Findings include: According to the hospice policy, titled Care/Service Coordination, dated 10/2020, timely and ongoing communication is the responsibility of each team member and will be appropriate to the needs and abilities of the patient, and relevant to the care/service provided. The case manager will be responsible for cooperative care planning in order to assure that goals, actions, and the interrelationship of services is not duplicated and to minimize the potential for missed or conflicting services. 1. Patient #3 had a hospice admission date of 3/2/22 and received hospice services while residing in a nursing home. Review of the clinical record on revealed the following: a. The Plan of Care (POC), dated 3/2/22 to 5/30/22, included Interdisciplinary Group (IDG) orders for skilled nursing, hospice aide, spiritual counseling care (SCC), social worker and music therapy services. b. A hospice benefit election form, dated 3/2/22. c. A Long Term Care Coordinated POC, dated 3/2/22, which identified the contact names of the hospice staff providing services to the patient including the nurse, hospice aide, social worker and chaplain. On 3/15/22 at 11:44 PM, the surveyor completed scheduled visit to the patient's nursing home to observe Staff E, Registered Nurse (RN), provide cares and reviewed the documentation provided by hospice staff to the nursing home. Review of the patient's hospice medical record maintained at the nursing home revealed the following documents were missing: the hospice benefit election form signed by the patient's representative and the names of the hospice staff providing cares to the patient. On 3/15/22 at 12:43 PM, during an interview, Staff E, RN, explained it was the hospice RN's responsibility to ensure the nursing home received the required hospice documentation. 2. Patient #10 had a hospice admission date of 5/27/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 1/22/22 to 3/22/22, included IDG orders for skilled nursing services, hospice aide services, music therapy, social work and SCC services. b. The clinical record included documentation of IDG meeting notes, dated 2/23 and 3/9/22. On 3/16/22 at 8:26 AM, the surveyor completed an unscheduled visit to the patient's nursing home and reviewed the documentation provided by hospice staff to the nursing home. Review of the patient's hospice medical record maintained at the nursing home revealed the following documents were missing: the IDG meeting notes, dated 2/23 and 3/9/22. In an interview, during the same unscheduled visit to the patient's nursing home, the Director of Nursing for the nursing home reported all of the documentation provided by hospice staff was in the patient's hospice chart maintained at the nursing home; there were not any documents that had not been filed. The Administrator and Clinical Manager received the above information. On 3/21/22 at 1:35 PM, during an interview, the Administrator reported hospice staff were unable to find further information.