Every finding on record at West Coast Healthcare, LLC

Based on interview and record review, the hospice failed to ensure the grievance was thoroughly investigated as per the hospice's P&P for four nonsampled patients (Patients A, B, C, and D).  This failure created the risk of violating the patient's rights and not providing quality of care and services to these patients.  Findings: --- The hospice's P&P titled Resolution of Patient Conflicts, Grievance or Complaints reviewed 9/1/24, showed the hospice will investigate complaints made by a patient, the patient's representative (if any), and the patient's caregiver. Review of the hospice's grievance log was conducted on 11/12/25.  The grievance log showed the complaints were filed on the following dates:-On 4/15/25, a complaint about the hospice staff who signed in for Patient A but did not provide care.-On 8/2 and 8/28/24, a complaint about the hospice staff who did not communicate well and the needs were not addressed for Patient B.-On 2/8/23, a complaint about the hospice staff who did not manage the skin condition for Patient C.-On 6/16/23, a complaint about the hospice staff related to the visit schedule of the multiple disciplines, the lack of training about DME, and providing for personal care for Patient D. However, review of the hospice's documents failed to show documented evidence of an interview conducted with the alleged staff.  On 11/25/25 at 1258 hours, an interview and concurrent document review was conducted with the Administrator.  The Administrator was asked if they investigated the grievance filed.  The Administrator was asked if an interview with the alleged staff was conducted.  The Administrator replied "yes, I have to."  The Administrator was asked to provide the documents for the staff interview.  The Administrator reviewed the grievance log and stated there was none documented.  The Administrator was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the comprehensive assessments were completed no later than five calendar days after the election of hospice care for eight of 19 sampled patients (Patients 1, 5, 6, 8, 9, 10, 15, and 17).  This failure had the potential for not addressing the care needs for these patients. Findings: --- XX.  Review of Patient 8's clinical record was initiated on 11/12/25.  The clinical record showed the SOC was 6/6/25.  The patient was certified for hospice services during the certification periods from 6/6/25 to 9/3/25 and 9/4/25 to 12/2/25. Review of the RN Hospice Start of Care dated 6/6/24, showed the RN had performed an assessment.However, RN 1 failed to assess the patient's weight as part of the initial comprehensive assessment no later than 5 calendar days after the election of hospice care.On 11/26/25 at 1017 hours, an interview and concurrent clinical record review were conducted with the DPCS.  The DPCS was informed on Patient 8's missed weight or MAC measurement assessment from the SOC.  The DPCS  verified she could not find any weight or MAC measurement on Patient 8's SOC RN visit documentation. XX. Review of Patient 10's clinical record was initiated on 11/12/25.  The clinical record showed the SOC was 12/3/24.  The patient was certified for hospice services during certification periods from 12/3/25 to 3/2/25, 3/3/25 to 5/31/25, 6/1/25 to 7/30/25,  7/31/25 to 9/28/25, and  9/29/25 to 11/27/25 and 11/28/25 to 1/26/25. *Review of the RN Hospice Start of Care dated 12/3/24, showed the RN had performed an assessment.However, RN 1 failed to assess the patients weight as part of the initial comprehensive assessment no later than 5 calendar days after the election of hospice care. On 11/25/25 at 1442 hours, an interview and  a concurrent clinical record review were conducted with the DPCS.  The DPCS was asked if weight or MAC measurement should be conducted every SOC visit.  The DPCS stated weight or MAC measurement should be measured every SOC visit.  The DPCS was informed of the missing weight or MAC measurements and  DPCS was further asked if she could find any documentation of weight or MAC measurements from Patient 10's SOC RN visit.  The DPCS verified she could not find any documentation and acknowledged it should have been done.    The hospice's P&P titled Patient Assessments reviewed 9/1/24, showed the hospice will conduct and document in writing a patient specific comprehensive assessment that identifies the patient's need for hospice care and services, and the patients' need for physical, psychosocial, emotional, and spiritual care.  The Interdisciplinary Group/Team (IDG/IDT) in consultation with the patients' attending physician (if any), will complete the comprehensive assessment no later than five calendar days after the election of hospice benefit. 1.  Review of Patient 15's clinical record was initiated on 11/20/25.  The clinical record showed the SOC was 9/9/24.  The patient was certified for hospice services during the certification periods from 9/9/24 to 12/7/24, 12/8/24 to 3/7/25, 3/8/25 to 5/6/25, 5/7/25 to 7/5/25, 7/6/25 to 9/3/25, 9/4/25 to 11/2/25  and 11/3/25 to 1/1/26.   *Review of the RN Hospice Start of Care dated 9/9/24, showed the RN had performed an assessment.However, there was no documented evidenced the RN 1 assessed the patients weight as part of the completion of the initial comprehensive assessment no later than 5 calendar days after the election of hospice care.*Review of the clinical records showed the MSW conducted an initial evaluation dated 9/24/25.  However, the MSW failed to performed the initial comprehensive assessment no later than 5 calendar days after the election of hospice care.On 11/25/25 at 1518 hours an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was asked if the height and weight needed to be taken.  The Administrator replied, we check the MAC instead of the weight.  The Administrator was also asked if the MAC was documented.   The Administrator reviewed the clinical records and replied, it was not documented on the notes.  The Administrator was further ask as to the timeline of the initial MSW comprehensive assessment.  The Administrator replied there was a missed visit on 9/20/25, the evaluation was conducted more than 5 calendar days from the SOC.  The Administrator was informed and acknowledged the findings.  2.  Review of Patient 17's clinical record was initiated on 11/20/25.  The clinical record showed the SOC was 3/5/25.  The patient was certified for hospice services during the certification periods from 3/5/25 to 6/2/25, 6/3/25 to 8/31/25, 9/1/25 to 10/30/25 and 10/31/25 to 12/29/25.  Review of the RN Hospice Start of Care dated 3/5/25, showed the RN 1 had performed an assessment. *However, the RN 1 failed to assess the patients weight as part of the initial comprehensive assessment no later than 5 calendar days after the election of hospice care.Further review of the RN Hospice Start of Care dated 3/5/25 showed a documentation for a Chaplain referral. *However, review of the clinical records showed the Chaplain 1 conducted the initial evaluation on 4/3/25 which was more than 5 calendar days after the election of hospice care.On 11/20/25 at 1527 hours, an interview and concurrent clinical record review was conducted with the Volunteer Coordinator/ HR/Intake Manager.  The Volunteer Coordinator/ HR/Intake Manager was asked if there was other Chaplain evaluation notes after the SOC.  The Volunteer Coordinator/ HR/Intake Manager replied, it was the only Chaplain evaluation notes.On 11/25/25 at 1437 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was asked as to the timeline of the completion of the Chaplain initial evaluation.  The Administrator replied, within 5 days from the SOC.  The Administrator was informed and acknowledged the findings.  3.  Review of Patient 9's clinical record was initiated on 11/19/25.  The clinical record showed the SOC was 1/14/25.  The patient was certified for hospice services during the certification periods from 1/14/25 to 4/13/25, 4/14/25 to 6/12/25, 6/13/25 to 8/11/25, 8/12/25 to 10/10/25 and 10/11/25 to 12/925.Review of the RN Hospice Start of Care dated 1/14/25, showed the RN 1 had performed an assessment. Further review of the clinical records showed the MSW conducted an initial evaluation dated 1/24/25.   However, the MSW failed to performed the initial comprehensive assessment no later than 5 calendar days after the election of hospice care.On 11/26/25 at 0958 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was asked as to the timeline of the completion of the MSW initial evaluation.  The Administrator reviewed the clinical record and replied, there was a coordination note on 1/20/25 and should be within 5 days if the family was agreeable.  The Administrator was informed and acknowledged the findings.  4.   Review of Patient 1's closed clinical record was initiated on 11/14/25.  The clinical record showed the SOC was 12/18/24.  The patient was certified for hospice services during the certification periods from 12/18/24 to 3/17/25, 3/18/25 to 6/15/25 and 6/16/25 to 8/2/25.  The patient passed away on 8/2/25. Review of the RN Hospice Start of Care dated 12/18/24, showed the RN 3 had performed an assessment.However, there was no documented evidenced the RN 3 assessed the patients weight as part of the completion of the initial comprehensive assessment no later than 5 calendar days after the election of hospice care.Further review of the RN Hospice Start of Care dated 12/18/24 on the section of  "Is the patient /caregiver open to Volunteer services to meet social /family support need" showed "yes, Volunteer Coordinator notified of request".  The reason for the Volunteer services was for errands and emotional support (telephone).However, review of the closed clinical record failed to show a volunteer coordinator visited the patient no later than 5 calendar days after the election of hospice care.On 11/25/25 at 1135 hours, an interview and concurrent closed clinical record review was conducted with the Administrator.  The Administrator was asked if there was a documentation of the patients' weight was taken on the initial comprehensive assessment. The Administrator reviewed the closed clinical record and replied none was documented.  The Administrator was also asked if the Volunteer visit was conducted.  The Administrator reviewed the closed clinical record and replied, typically the Social Worker will follow up for the volunteer request, MSW saw the patient on 12/20/24 but does not document the need for Volunteer, we don't have Volunteer at that time.  The Administrator was informed and acknowledged the findings.      Crossed reference: L-554 5.   Review of Patient 6's clinical record was initiated on 11/18/25.  The clinical record showed the SOC was 9/25/24.  The patient was certified for hospice services during the certification periods from 9/25/24 to 12/23/24, 12/24/24 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, 9/20/25 to 11/18/25 and 11/19/25 to 1/17/25. Review of the RN Hospice Start of Care dated 9/25/24, showed the RN 1 had performed an assessment. However, the RN 1 failed to assess the patients weight as part of the initial comprehensive assessment no later than 5 calendar days after the election of hospice care.On 11/25/25 at 0909 hours an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked if the MAC was documented.  The reviewed the clinical record and replied, no.  The  Administrator was informed and acknowledged the findings.  #.  Review of Patient 5's clinical record was initiated on 11/13/25.  The clinical record showed the SOC was 3/13/25.  The patient was certified for hospice services during the certification periods from 3/13/25 to 6/10/25, 6/11/25 to 9/8/25, 9/9/25 to 11/7/25 and 11/8/25 to 1/6/26. Review of the RN Hospice Start of Care dated 3/13/25, showed the RN 1 had performed an assessment. However, the RN 1 failed to assess the patients weight as part of the initial comprehensive assessment no later than 5 calendar days after the election of hospice care On 11/26/25 at 0811 hours an interview and concurrent clinical record review was conducted with the Administrator. The reviewed the clinical record and replied, no.  The  Administrator was informed and acknowledged the findings.  The hospice's P&P titled Patient Assessments reviewed 9/1/24, showed the hospice will conduct and document in writing a patient specific comprehensive assessment that identifies the patient's need for hospice care and services, and the patients' need for physical, psychosocial, emotional, and spiritual care.  The Interdisciplinary Group/Team (IDG/IDT) in consultation with the patients' attending physician (if any), will complete the comprehensive assessment no later than five calendar days after the election of hospice benefit. 1.  Review of Patient 15's clinical record was initiated on 11/20/25.  The clinical record showed the SOC was 9/9/24.  The patient was certified for hospice services during the certification periods from 9/9/24 to 12/7/24, 12/8/24 to 3/7/25, 3/8/25 to 5/6/25, 5/7/25 to 7/5/25, 7/6/25 to 9/3/25, 9/4/25 to 11/2/25, and 11/3/25 to 1/1/26. The Hospice Informed Consent/Election of Hospice Benefit dated 9/9/24, showed hospices services was elected.  *Review of the RN Hospice Start of Care dated 9/9/24, showed the RN had performed an assessment.However, there was no documented evidenced RN 1 assessed the patient's weight as part of the completion of the initial comprehensive assessment no later than 5 calendar days after the election of hospice care.*Review of the clinical records showed the MSW conducted an initial evaluation dated 9/24/25.  However, the MSW failed to performed the initial comprehensive assessment no later than 5 calendar days after the election of hospice care.On 11/25/25 at 1518 hours an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was asked if the height and weight needed to be taken.  The Administrator replied, we check the MAC instead of the weight.  The Administrator was also asked if the MAC was documented.   The Administrator reviewed the clinical records and stated it was not documented on the notes.  The Administrator was asked as to the timeline of the initial MSW comprehensive assessment.  The Administrator stated there was a missed visit on 9/20/25 and the evaluation was conducted more than 5 calendar days from the SOC.  The Administrator was informed and acknowledged the findings. 2.  Review of Patient 17's clinical record was initiated on 11/20/25.  The clinical record showed the SOC was 3/5/25.  The patient was certified for hospice services during the certification periods from 3/5/25 to 6/2/25, 6/3/25 to 8/31/25, 9/1/25 to 10/30/25, and 10/31/25 to 12/29/25.The Authorization & Consent for Treatment dated 3/5/25, showed hospices services was elected.    Review of the RN Hospice Start of Care dated 3/5/25, showed RN 1 had performed an assessment. *However, RN 1 failed to assess the patients weight as part of the initial comprehensive assessment no later than 5 calendar days after the election of hospice care.Further review of the RN Hospice Start of Care dated 3/5/25, showed a documentation for a Chaplain referral. *However, review of the clinical records showed Chaplain 1 conducted the initial evaluation on 4/3/25 which was more than 5 calendar days after the election of hospice care.On 11/20/25 at 1527 hours, an interview and concurrent clinical record review was conducted with the Volunteer Coordinator/ HR/Intake Manager.  The Volunteer Coordinator/ HR/Intake Manager was asked if there was other Chaplain evaluation notes after the SOC.  The Volunteer Coordinator/ HR/Intake Manager replied, it was the only Chaplain evaluation notes.On 11/25/25 at 1437 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was asked as to the timeline of the completion of the Chaplain initial evaluation.  The Administrator replied, within 5 days from the SOC.  The Administrator was informed and acknowledged the findings.  3.  Review of Patient 9's clinical record was initiated on 11/19/25.  The clinical record showed the SOC was 1/14/25.  The patient was certified for hospice services during the certification periods from 1/14/25 to 4/13/25, 4/14/25 to 6/12/25, 6/13/25 to 8/11/25, 8/12/25 to 10/10/25 and 10/11/25 to 12/9/25.The Hospice Informed Consent/Election of Hospice Benefit dated 1/14/25, showed hospices services was elected.  Review of the RN Hospice Start of Care dated 1/14/25, showed RN 1 had performed an assessment. Further review of the clinical records showed the MSW conducted an initial evaluation dated 1/24/25.   However, the MSW failed to perform the initial comprehensive assessment no later than 5 calendar days after the election of hospice care.On 11/26/25 at 0958 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was asked as to the timeline of the completion of the MSW initial evaluation.  The Administrator reviewed the clinical record and stated there was a coordination note on 1/20/25 and should be within 5 days if the family was agreeable.  The Administrator was informed and acknowledged the findings.  4.   Review of Patient 1's closed clinical record was initiated on 11/14/25.  The clinical record showed the SOC was 12/18/24.  The patient was certified for hospice services during the certification periods from 12/18/24 to 3/17/25, 3/18/25 to 6/15/25 and 6/16/25 to 8/2/25.  The patient expired on 8/2/25. The Hospice Informed Consent/Election of Hospice Benefit dated 12/18/24, showed hospices services was elected.  Review of the RN Hospice Start of Care dated 12/18/24, showed the RN 3 had performed an assessment.However, there was no documented evidence RN 3 assessed the patient's weight as part of the completion of the initial comprehensive assessment no later than 5 calendar days after the election of hospice care.Further review of the RN Hospice Start of Care dated 12/18/24, on the section of  "Is the patient /caregiver open to Volunteer services to meet social /family support need" showed "yes, Volunteer Coordinator notified of request".  Documentation showed the reason for the volunteer services was for errands and emotional support (telephone).However, review of the closed clinical record failed to show a volunteer coordinator visited the patient no later than 5 calendar days after the election of hospice care.On 11/25/25 at 1135 hours, an interview and concurrent closed clinical record review was conducted with the Administrator.  The Administrator was asked if there was a documentation of the patients' weight was taken on the initial comprehensive assessment. The Administrator reviewed the closed clinical record and replied none was documented.  The Administrator was also asked if the Volunteer visit was conducted.  The Administrator reviewed the closed clinical record and replied, typically the Social Worker will follow up for the volunteer request, MSW saw the patient on 12/20/24 but does not document the need for Volunteer, we don't have Volunteer at that time.  The Administrator was informed and acknowledged the findings.      Crossed reference: L-554 5.   Review of Patient 6's clinical record was initiated on 11/18/25.  The clinical record showed the SOC was 9/25/24.  The patient was certified for hospice services during the certification periods from 9/25/24 to 12/23/24, 12/24/24 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, 9/20/25 to 11/18/25 and 11/19/25 to 1/17/25. The Authorization & Consent for Treatment dated 9/25/24, showed hospices services was elected.  Review of the RN Hospice Start of Care dated 9/25/24, showed the RN 1 had performed an assessment. However, the RN 1 failed to assess the patients weight as part of the initial comprehensive assessment no later than 5 calendar days after the election of hospice care.On 11/25/25 at 0909 hours an interview and concurrent clinical record review was conducted with the Administrator. The Administrator was asked if the MAC was documented.  The reviewed the clinical record and replied, no.  The  Administrator was informed and acknowledged the findings.  6.  Review of Patient 5's clinical record was initiated on 11/13/25.  The clinical record showed the SOC was 3/13/25.  The patient was certified for hospice services during the certification periods from 3/13/25 to 6/10/25, 6/11/25 to 9/8/25, 9/9/25 to 11/7/25 and 11/8/25 to 1/6/26.The Hospice Informed Consent/Election of Hospice Benefit dated 3/12/25, showed hospices services was elected.   Review of the RN Hospice Start of Care dated 3/13/25, showed the RN 1 had performed an assessment. However, the RN 1 failed to assess the patients weight as part of the initial comprehensive assessment no later than 5 calendar days after the election of hospice care On 11/26/25 at 0811 hours an interview and concurrent clinical record review was conducted with the Administrator. The reviewed the clinical record and replied, no.  The  Administrator was informed and acknowledged the findings. 7.  Review of Patient 8's clinical record was initiated on 11/12/25.  The clinical record showed the SOC was 6/6/25.  The patient was certified for hospice services during the certification periods from 6/6/25 to 9/3/25 and 9/4/25 to 12/2/25.The Authorization & Consent for Treatment dated 6/6/25, showed hospices services was elected.  Review of the RN Hospice Start of Care dated 6/6/24, showed the RN had performed an assessment.However, RN 1 failed to assess the patient's weight as part of the initial comprehensive assessment no later than 5 calendar days after the election of hospice care.On 11/26/25 at 1017 hours, an interview and concurrent clinical record review were conducted with the DPCS.  The DPCS was informed on Patient 8's missed weight or MAC measurement assessment from the SOC.  The DPCS  verified she could not find any weight or MAC measurement on Patient 8's SOC RN visit documentation. 8. Review of Patient 10's clinical record was initiated on 11/12/25.  The clinical record showed the SOC was 12/3/24.  The patient was certified for hospice services during certification periods from 12/3/25 to 3/2/25, 3/3/25 to 5/31/25, 6/1/25 to 7/30/25,  7/31/25 to 9/28/25, and  9/29/25 to 11/27/25 and 11/28/25 to 1/26/25.The Hospice Informed Consent/Election of Hospice Benefit dated 12/3/24, showed hospices services was elected.  *Review of the RN Hospice Start of Care dated 12/3/24, showed the RN had performed an assessment.However, RN 1 failed to assess the patients weight as part of the initial comprehensive assessment no later than 5 calendar days after the election of hospice care. On 11/25/25 at 1442 hours, an interview and  a concurrent clinical record review were conducted with the DPCS.  The DPCS was asked if weight or MAC measurement should be conducted every SOC visit.  The DPCS stated weight or MAC measurement should be measured every SOC visit.  The DPCS was informed of the missing weight or MAC measurements and  DPCS was further asked if she could find any documentation of weight or MAC measurements from Patient 10's SOC RN visit.  The DPCS verified she could not find any documentation and acknowledged it should have been done.

Based on interview and record review, the hospice failed to ensure the comprehensive assessment included the assessment for volunteer need for one of 19 sampled patients (Patient 14).  This failure had the potential risk of not identifying and addressing the care needs for this patient.Findings: --- Review of Patient 14’s clinical record was initiated on 11/19/25. The clinical record showed the SOC was 8/1/24. The patient was certified for hospice services during the certification periods from 8/1/24 to 10/29/24, 10/30/24 to 12/28/24, 12/29/24 to 2/26/25, 2/27/25 to 4/27/25, 4/28/25 to 6/26/25, 6/27/25 to 8/25/25, 8/26/25 to 10/24/25, and 10/25/25 to 12/23/25.However, further review of the clinical record failed to show documented evidence the initial comprehensive assessment included the assessment of the patient’s need for volunteer services.On 11/21/25 at 1425 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. They both verified and acknowledged the findings.

Based on observation, interview, and record review, the hospice failed to include all current medications included specific indications and parameters for its use for one of 19 sampled patients (Patient 5).  This failure had the potential for the patients to not receive the appropriate care and necessary services and negatively affect the patients' well-being. Findings: --- The hospice's P&P Titled Medication Management reviewed 9/8/25 showed medication assessments will identify all medications, both prescription and non-prescription the patient is taking and document in the clinical record.  Medication monitoring occurs at each scheduled clinical visit and will include gathering appropriate information to develop an accurate medication history and a current medication profile. Medication assessments are continuous and ongoing, occur at every scheduled clinical visit and are documented in the clinical record. 1.  Review of Patient 5's clinical record was initiated on 11/13/25.  The clinical record showed the SOC was 3/13/25.  The patient was certified for hospice services during the certification periods from 3/13/25 to 6/10/25, 6/11/25 to 9/8/25, 9/9/25 to 11/7/25 and 11/8/25 to 1/6/26. The Medication Profile showed the patients' medications included the following: -acetaminophen (analgesic) 325 mg two tablets PO Q6H PRN for pain and temperature NTE 3gms in 24H-Betadine (antiseptic) 5% topical spray, QD for wound care-Calcium citrate magnesium and zinc with Vitamin D3 (supplement) one tablet PO BID -Centrum silver women 8 mg Iron -400 mcg -50 mcg (supplement) one tablet PO QD-Dorzolamide- timolol (glaucoma) 2%-0.5% eye drops in a dropperette -ophthalmic one dropperette  QD-Glimepiride (antidiabetic) 2 mg tablet one tablet  QD-Humalog Kwikpen U-100 (antidiabetic) Insulin 100 unit/ml subcutaneous four times a day-hydrocodone 5mg /acetaminophen 325 mg (pain medication) one tablet orally Q4H PRN-Lantus Solostar U-100 (antidiabetic) Insulin 100 Units/Ml (3ml) subcutaneous pen 11 unit subcutaneous QAM and 4 unit QPM-Latanoprost 0.005% (glaucoma) eye drops -ophthalmic one drop at QHS-Medihoney (honey) 100% (wound care) topical paste - topical as per instructions three times a week-Metformin (antidiabetic) 500 mg one tablet BID-Metoprolol succinate ER (anti hypertension) 50 mg tablet extended release 24H one tablet QD, hold for SBP less than 100 -Miralax (constipation) 17 gram/dose oral powder 17 grams QD-Oxygen Gas inhalation (Shortness of breath) 2-5 Liter PRN -Preservision Areds 2 Plus Multivitamin (vision supplement) 200 mcg-15mcg-5 Mg -11mg capsule -Senna Plus (constipation) 8.5 mg-50 mg tablet one tablet BID-Seroquel (agitation) 25 mg tablet one tablet QAM-Sertraline (agitation) 50 mg tablet QD-Simvastatin (anti cholesterol) 10 mg tablet QHS-Tolterodine Er  (over reactive bladder) 4mg capsule Extended release 24H  one capsule QD-Trulicity (antidiabetic) 1.5 mg/ 0.5ml subcutaneous pen injector 1.5 mg Weekly every Wednesday-Vitamin C(supplement) 500 mg tablet 0ne tablet QD-Xarelto (blood thinner) 10 mg tablet one tablet QDA joint home visit with RN 1 was conducted on 11/13/25 at 0900 hours, to the B&C facility where Patient 5 resided.  Review of the patients' medications included the following instructions: -Betadine (antiseptic) 5% topical spray, QD for wound care.  However, the spray preparation was changed into swab.-Medi honey (honey) 100% (wound care) topical paste - topical as per instructions three times a week.  However, the medication was discontinued. -Metoprolol succinate ER (anti hypertension) 50 mg tablet extended release 24H one tablet QD hold for SBP less than 100.  However, the instructions when to hold the medications was not included on the medication label.-Trulicity (antidiabetic) 1.5 mg/ 0.5ml subcutaneous pen injector 1.5 mg Weekly every Wednesday.  However, the medication was given every Friday instead of every Wednesday as ordered. In addition, the patient was taking Simethicone 80 mg 1/2 tablet Q6H PRN for flatulence.  However, the medication was not included in the medication profile. On 11/13/25 at 0957 hours, an interview and concurrent clinical record review was conducted with the RN 1 and the PCG.  The RN 1 acknowledged the findings. On 11/26/25 at 0800 hours, the Administrator was informed and acknowledged the findings.   xx. Review of Patient 7’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 7/27/24. The patient was certified for hospice during the certification periods from 7/27/24 to 10/24/24, 10/25/24 to 1/22/25, 1/23/25 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, and 9/20/25 to 11/18/25. The Medication Profile showed the patients' medications included the following:-Acetaminophen 500 mg tablet , to take one tablet every 4 hours as needed for pain level 1-3/10 , do not exceed 3 g of acetaminophen in 24 hours  from all sources,-Acetaminophen 650 mg rectal suppository, to insert one suppository rectally every 4 hours as needed for temperature greater than 100 F, do not exceed 33 g of acetaminophen in 24 hours  from all sources,-Arnicare cream 7%, to apply thin layer on right heel topically at bedtime as needed for right heel pain,-Bisacodyl 10 mg rectal suppository, to insert one rectal suppository daily as needed , for constipation,-Bupropion Hcl Xl 150 mg extended release oral tablet, to take one oral tablet two times daily, indicated  for depression, -Diazepam 5 mg oral tablet, to take one tablet at bedtime, for anxiety,-Diclofenac 1% topical gel, to apply 2 inch topically on right heel 3 times daily as needed for right heel pain,-Dulcolax 5 mg tablet delayed release oral tablet, to take one tablet two times daily for bowel movement,-Glipizide 2.5 mg-Metformin 500 mg toral ablet , to take one tablet 2 times daily for diabetes mellitus,-Hyoscyamine 0.125 mg sublingual tablet, to take one tablet every 4 hours as needed for secretions,-Ipratropium 0.5 mg - Albulterol 3 mg(2.5 mg base) 3 ml nebulization solution inhalation, to take 3 mg every 4 hours as needed for cough/ wheezing.  However, medication not available during the visit.-Lidocaine Pain relief 4% topical patch, to apply 1 patch daily for 12 hours in 24 hours to affected area for pain,-Lorazepam 0.5 mg oral tablet, to take one tablet every 4 hours as needed for anxiety,-Melatonin 10 mg oral capsule, to take one capsule at bedtime for appetite stimulant, -Milk of Magnesia Concentrated 2,400 mg/10 ml oral suspension, to take 30 ml daily as needed for constipation, -Mirtazepine 30 mg oral tablet, to take one tablet at bedtime for appetite stimulant, -Morphine Concentrate 20 mg/ml oral syringe , to take 5mg orally every 2 hours as needed for pain or shortness of breath, -Nitroglycerin 0.4mg sublingual tablet, to take 1 tablet under the tongue on the first sign of angina episode, may take 1 tablet every 5 minutes as needed, for up to 15 minutes.  Note: Do not take more than 3 tablets in 15 minutes,-Ondansetron Hcl 4 mg oral tablet, to take 1 tablet every four hours as needed for nausea or vomiting,-Oxygen Gas for inhalation via nasal cannula for 2-5 liters as needed for shortness of breath,-Pepto-Bismol 262 mg/15 ml oral suspension, to take 30 ml 2 times daily as needed for upset stomach,-Polyethylene Glycol 3350 17 grams, 17 grams to mix with 8 oz of water or juice , to take daily as needed for constipation.-Trazodone 100 mg oral tablet, to take 2 tablets  at bedtime for sleep,-Tussin DM 10 mg-100mg/5ml, to take 10 ml every 4 hours as needed for cough.On 11/14/25 at 1320 hours, a hospice home visit observation was conducted on Patient 7 with MSW.  At 1335 hours, medication profile was reviewed with MSW.  Patient 7's medications on hospice medication profile printed dated 11/12/25 were checked if all are available.  However, Patient 7's Ipratropium 0.5mg-Albuterol 3mg nebulization solution was not available.  Patient 7's caregiver was also asked  if he can find Patient 7's  Ipratropium 0.5mg-Albuterol 3mg nebulization solution medication.  Patient 7's caregiver was not able to find the mentioned medication.  Patient 7 was asked if he still takes Ipratropium 0.5mg-Albuterol 3mg nebulization solution medication via inhalation.  Patient 7 stated he was still taking it. MSW also could not find the Ipratropium 0.5mg-Albuterol 3mg nebulization solution from Patient 7's medication tray.   The hospice's P&P Titled Medication Management reviewed 9/8/25, showed medication assessments will identify all medications, both prescription and non-prescription the patient is taking and document in the clinical record.  Medication monitoring occurs at each scheduled clinical visit and will include gathering appropriate information to develop an accurate medication history and a current medication profile. Medication assessments are continuous and ongoing, occur at every scheduled clinical visit and are documented in the clinical record. 1.  Review of Patient 5's clinical record was initiated on 11/13/25.  The clinical record showed the SOC was 3/13/25.  The patient was certified for hospice services during the certification periods from 3/13/25 to 6/10/25, 6/11/25 to 9/8/25, 9/9/25 to 11/7/25, and 11/8/25 to 1/6/26. The Medication Profile showed the patient's medications included the following: -acetaminophen (analgesic) 325 mg two tablets PO Q6H PRN for pain and temperature notto exceed 3 gms in 24 hours-Betadine (antiseptic) 5% topical spray QD for wound care-calcium citrate magnesium and zinc with vitamin D3 (supplement) one tablet PO BID -Centrum Silver Women 8 mg Iron 400 mcg -50 mcg (supplement) one tablet PO QD-dorzolamide timolol (used to treat glaucoma) 2%-0. 5% eye drops one dropperette  QD-glimepiride (antidiabetic) 2 mg tablet one tablet  QD-Humalog KwikPen U-100 (antidiabetic) 100 units/ml subcutaneous four times a day-hydrocodone 5 mg/acetaminophen 325 mg (opioid analgesic) one tablet orally Q four hours PRN-Lantus SoloStar U-100 (antidiabetic) 100 units/ml (3ml) subcutaneous 11 units QAM and 4 units QPM-latanoprost 0.005% (used to treat glaucoma) eye drops one drop at QHS-Medihoney 100% (wound dressing)  topical as per instructions three times a week-metformin (antidiabetic) 500 mg one tablet BID-metoprolol succinate ER (antihypertension) 50 mg tablet extended release 24 hours one tablet QD, hold for SBP less than 100 -Miralax (lavxative) 17 gram/dose oral powder 17 grams QD-oxygen gas inhalation  2-5 liters PRN -Preservision Areds 2 Plus Multivitamin (supplement) 200 mcg-15mcg-5 Mg -11mg capsule -Senna Plus (laxative) 8.5 mg-50 mg tablet one tablet PO BID-Seroquel (antipsychotic) 25 mg tablet one tablet PO QAM-sertraline (antidepressant) 50 mg tablet PO QD-simvastatin (antilipemic) 10 mg tablet PO QHS-tolterodine Er  (used to treat overactive bladder) 4 mg capsule one capsule PoQD-Trulicity (antidiabetic) 1.5 mg/ 0.5ml subcutaneous pen injector 1.5 mg weekly every Wednesday-vitamin C (supplement) 500 mg tablet one tablet QD-Xarelto (anticoagulant) 10 mg one tablet QD A joint home visit with RN 1 was conducted on 11/13/25 at 0900 hours, to the B&C facility where Patient 5 resided.  Review of the patient's medications included the following instructions: -Betadine 5% topical spray QD for wound care.  However, the spray preparation was changed into swab.-Medihoney 100% topical as per instructions three times a week.  However, the medication was discontinued. -metoprolol succinate ER 50 mg tablet extended release 24 hours one tablet QD, hold for SBP less than 100.  However, the instructions when to hold the medication was not included on the medication label.-Trulicity  1.5 mg/ 0.5ml subcutaneous pen injector 1.5 mg weekly every Wednesday.  However, the medication was given every Friday instead of every Wednesday as ordered. In addition, the patient was taking simethicone (antiflatulence) 80 mg one half tablet Q six hours PRN for flatulence.  However, the medication was not included in the medication profile. On 11/13/25 at 0957 hours, an interview and concurrent clinical record review was conducted with the RN 1 and the PCG.  RN 1was informed and acknowledged the findings. On 11/26/25 at 0800 hours, the Administrator was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the updated comprehensive assessments included the changes that had occurred since the initial assessment, information on the patient’s progress, and reassessment of the patient’s responses for four of 19 sampled patients (Patient 4, 8, 18, and 19). This failure created the risk of not addressing the care needs for these patients.Findings: --- Review of the hospice’s P&P titled Plan of Care Process reviewed 9/1/24, showed the update of the comprehensive assessment will be accomplished by the Hospice IDG/IDT, in collaboration with the individual’s attending physician, if any, and will evaluate changes that have taken place since the initial assessment. The interdisciplinary POC will be developed by the IDG/IDT, upon completion of the comprehensive assessment within 15 days from start of care.xx. Review of Patient 4’s closed clinical record was initiated on 11/14/25. The clinical record showed the SOC was 12/23/24. The patient was certified for hospice services during the certification period 12/23/24 to 3/22/25. The patient was discharged from hospice services on 2/4/25.Review of the RN Visit Note Report dated 12/23/24, showed a small abrasion to the left forearm, covered with Tegaderm (used to protect and cover wounds).The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 1/13/25, showed no documented evidence the IDG had discussed the patient’s small abrasion to the left forearm.On 11/21/25 at 1114 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. They both verified and acknowledged the findings. XX.  Review of Patient 8's clinical record was initiated on 11/12/25.  The clinical record showed the SOC was 6/6/25.  The patient was certified for hospice services during the certification periods from 6/6/25 to 9/3/25 and 9/4/25 to 12/2/25. Review of Patient 8's RN visit note dated 9/22/25 showed Patient 8 was with itchiness and with generalized small apparent bug bites.   Review of Patient 8's SN visit note dated 9/29/25 showed Patient 8 was with abscess on pubic area. *However, there was no documentation from the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 10/1/25 showing Patient 8's with itchiness and generalized small apparent bug bites and abscess on pubic area was discussed. On 11/26/25 at 1017 hours,  an interview and concurrent clinical record review was conducted with the DPCS.  The DPCS was asked to show any documentation discussing update plan of care on Patient 8's itchiness, generalized small apparent bug bite and abscess  on pubic area. The DPCS acknowledged she could not find any documentation and verified the plan of care should have been updated. XX. Review of Patient 18 was initiated on 11/12/25.  The clinical record showed the SOC was 2/24/25.  The patient was certified for hospice services during certification periods 2/24/25 - 5/24/25, 5/25/25 to 8/22/25, 8/23/25 to 10/21/25 and 10/22/25 to 12/20/25.  Review of the RN Visit Note Report dated  10/13/25 showed Patient 18 with facial bruising.  The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 10/15/25, showed no documented evidence the IDG had discussed the patient’s facial bruising. On 11/26/25 at 0859 hours, an interview and concurrent clinical record review was conducted with the DPCS.  The DPCS was asked if she could provide any updated plan of care  on Patient 18's facial bruising.  The DPCS verified she could not find any documentation and acknowledge there should have been a plan of care on Patient 18's facial bruising.     XX.  Review of 19's clinical record was initiated on 11/12/25.  The clinical record showed the SOC was 5/21/24. The patient was certified for hospice services during certification period periods 5/21/24 to 8/18/24, 8/19/24 to 11/16/24, 11/17/24 to 1/15/25, 1/16/25 to 3/16/25, 3/17/25 to 5/15/25, 5/16/25 to 7/14/25, 7/15/25 to 9/12/25, 9/13/25 to 11/11/25 and 11/12/25 to 1/10/26. Review of Patient 19's RN visit note dated 11/13/25 showed patient reports new right shoulder pain with movement. However, there was no documentation from the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 11/19/25 showing Patient 19's new right shoulder pain with movement was discussed.  On 11/26/25 at 1532 hours, an interview and concurrent clinical record review was conducted with the DPCS.  The DPCS was asked what was the agency's process if patient had a change of condition.  The DPCS stated the licensed nurse should assess the patient, inform the patient/caregiver, inform physician.  The DPCS was further asked if there was a need to initiate and develop a care plan.  The DPCS stated it is required to initiate and develop a care plan for any change of condition.  The DPCS was informed of Patient 19's change of condition dated 11/13/25 and verified there was no care plan initiated and developed for addressing Patient 19's new right shoulder pain.

Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POC for 10 of 19 sampled patients (Patients 1, 3, 5, 6, 7, 11, 13, 15, 16, and 17).  This failure created the risk of not providing appropriate, consistent, and quality care to the patients. Findings: --- xx. Review of Patient 3’s closed clinical record was initiated on 11/13/25. The clinical record showed the SOC was 1/25/24. The patient was certified for hospice during the certification periods from 1/25/24 to 4/23/24, 4/24/24 to 7/22/24, 6/14/24 to 8/12/24, 8/13/24 to 10/11/24, 10/12/24 to 12/10/24, 12/11/24 to 2/8/25, 2/9/25 to 4/9/25, and 4/10/25 to 6/2/25. The patient expired on 6/2/25.Review of the physician’s order dated 3/26/25, showed an order for MSW effective 4/13/25 for 1W1 and 1Q2W2 (one visit every other week for two weeks).*However, the MSW had no documented visits for the weeks 4/27/25 to 5/3/25, 5/4/25 to 5/10/25, and 5/11/25 to 5/17/25.On 11/13/25 at 1500 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator stated if the visit was missed for the week, a visit should have been rescheduled or offered a visit for the following week. The Administrator verified and acknowledged the finding.xx. Review of Patient 7’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 7/27/24. The patient was certified for hospice during the certification periods from 7/27/24 to 10/24/24, 10/25/24 to 1/22/25, 1/23/25 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, and 9/20/25 to 11/18/25.a.Review of the physician’s order dated 9/5/25, showed an order for HA visits effective 9/21/25 for 2W8 and 1W1.*However, the HA notes for Week 5 (10/12/25 to 10/18/25), showed one HA visit instead of two visits as per the physician’s order.b.Review of the physician’s order dated 10/27/25, showed an order for SN visits effective 10/26/25 for 3WK1, 2WK2, and 1WK1.*However, the SN notes for Week 7 (10/26/25 to 11/1/25) showed two SN visits instead of three visits as per the physician’s order.c.Review of the physician’s order dated 10/9/25, showed an order for MSW visits effective 10/26/25 for 1WK3.*However, the MSW had no documented visits for the week 10/26/25 to 11/1/25 and 11/2/to 11/8/25.On 11/21/25 at 1343 hours, an interview and concurrent clinical record review were conducted with the Administrator and DPCS. The Administrator stated the missed visits were reported, however, there was no documented evidence the missed visits were offered for another day. The Administrator and DPCS verified and acknowledged the findings.xx. Review of Patient 13’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 1/12/23. The patient was certified for hospice during the certification periods from 1/12/23 to 4/11/23, 4/12/23 to 7/10/23, 7/11/23 to 9/8/23, 9/9/23 to 11/7/23, 11/8/23 to 1/6/24, 1/7/24 to 3/6/24, 3/7/24 to 5/5/24, 5/6/24 to 7/4/24, 7/5/24 to 9/2/24, 9/3/24 to 11/1/24, 11/2/24 to 12/31/24, 1/1/25 to 3/1/25, 3/2/25 to 4/30/25, 5/1/25 to 6/29/25, 6/30/25 to 8/28/25, 8/29/25 to 10/27/25 and 10/28/25 to 12/26/25.Review of the physician’s order dated 8/14/25, showed an order may recert patient for next hospice certification period (8/29/25 to 10/27/25). Calendar frequency for SN effective 8/31/25 was 1WK 8.Review of the calendar of actual visits for SN for Week 7 (10/5/25 to 10/11/25) showed SN had two visits, 10/7/25 and 10/8/25.Review of the RN Visit Note Report dated 10/8/25, showed the visit type of SN Hospice PRN visit. In the narrative patient was found on the floor next to the bed on the right side, an unwitnessed fall. On inspection small bump on the right side of forehead measuring 0.8 cm x 1.2 cm. MD was notified and a new order was received for floor mat.*However, review of the physician’s order dated 10/8/25 failed to show an order for the PRN visit.On 11/21/25 at 1020 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. They both verified and acknowledged the findings.xx. Review of Patient 14’s clinical record was initiated on 11/19/25. The clinical record showed the SOC was 8/1/24. The patient was certified for hospice during the certification periods from 8/1/24 to 10/29/24, 10/30/24 to 12/28/24, 12/29/24 to 2/26/25, 2/27/25 to 4/27/25, 4/28/25 to 6/26/25, 6/27/25 to 8/25/25, 8/26/25 to 10/24/25 and 10/25/25 to 12/23/25.Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report Report dated 8/11/24, showed an HHA frequency effective 8/26/25 to 1WK1 and 2WK8.*However, the HA notes for the following weeks showed one HA visit instead of two visits as per POC.-Week 4 (9/14/25 to 9/20/25), and-Week 5 (9/21/25 to 9/27/25). On 11/21/25 at 1425 hours, an interview and concurrent clinical record review were conducted with the Administrator and DPCS. The Administrator stated the missed visits were reported, however, there was no documented evidence the missed visits were offered for another day. The Administrator and DPCS verified and acknowledged the findings. XX.  Review of Patient 16's clinical record was initiated on 11/12/25. The clinical record showed the SOC was 9/3/25. The patient was certified for hospice services during certification period 9/3/25 to 12/1/25. Review of Patient 16's physician order dated 9/5/25 showed an order for SN effective 9/3/25  for 2w1, 2w8.*However,  there was no documented SN visit for the week of 11/2/25 to 11/8/25. On 11/24/25 at 1304 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was asked if there was any documentation for Patient 16's SN visit for the week of 11/9/25 to 11/15/25.  The DPCS verified she could not find any SN visit documentation within that week.  The DPCS was further asked if there was any SN missed visit documentation and an any documentation that offer of SN visit within that week.  The DPCS verified it was missed visit and acknowledged she could not find any documentation of any SN visit or follow up visit was offered. XX.  Review of Patient 18 was initiated on 11/12/25.  The clinical record showed the SOC was 2/24/25.  The patient was certified for hospice services during certification periods 2/24/25 - 5/24/25, 5/25/25 to 8/22/25, 8/23/25 to 10/21/25 and 10/22/25 to 12/20/25.   Review of Patient 18's MD order dated 10/7/25 showed an order for HA visit effective 10/22/25 1w1, 2w8.*However, the HA notes for Week 3 (11/9/25 to 11/15/25), showed one HA visit instead of two visits as per the physician’s order. On 11/26/25 at 0859 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS  was asked if there was another HA visit documentation aside from 11/14/25 for Patient 18.  The DPCS  stated 11/10/25 was a missed HA visit.  The DPCS was further asked for any documentation that a follow up visit was offered.  The DPCS verified there was no documentation of a follow up HA visit was offered.      The hospice's P&P titled Plan of Care Process reviewed 9/1/24 showed to ensure that the care provided is in accordance with the written plan of care (POC), appropriately planned, and delivered in a timely manner to meet the patients 's and family's specific needs. #.  Review of Patient 15's clinical record was initiated on 11/20/25.  The clinical record showed the SOC was 9/9/24.  The patient was certified for hospice services during the certification periods from 9/9/24 to 12/7/24, 12/8/24 to 3/7/25, 3/8/25 to 5/6/25, 5/7/25 to 7/5/25, 7/6/25 to 9/3/25, 9/4/25 to 11/2/25 and 11/3/25 to 1/1/26. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/3, 9/17, 10/1, 10/15 and 10/29/25 showed the patients current problem list.  The list included an evaluation of patient/family mental coping and emotional stability. Review of the Nursing Visit notes dated 9/26 and 10/22/25 showed the RN 2 had performed an assessment.  The assessment included a section for the patients spiritual, psychosocial, social and emotional status. However, the RN 2 failed to follow the POC as the assessment for the patients spiritual, psychosocial, social and emotional were left blank. On 11/25/25 at 1524 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was asked if the SN needed to complete the assessment.  The Administrator replied yes.  The Administrator was also asked if the care plan was followed.  The Administrator reviewed the clinical records and acknowledged the findings. #.  Review of Patient 11's clinical record was initiated on 11/18/25.  The clinical record showed the SOC was 2/18/25.  The patient was certified for hospice services during the certification periods from 2/18/25 to 5/18/25, 5/19/25 to 8/16/25, 8/17/25 to 10/15/25 and 10/16/25 to 12/14/25. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 8/20, 9/3, 9/17, 10/15, 10/29 and 11/15/25 showed the patients current problem list.  The list included an evaluation of patient/family mental coping and emotional stability. Review of the Nursing Visit notes dated 10/7 and 10/29/25 showed the SN had performed an assessment.  The assessment included a section for the patients spiritual, psychosocial, social and emotional status. However, the RN 2 failed to follow the POC as the assessment for the patients spiritual, psychosocial, social and emotional were left blank. On 11/26/25 at 1030 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.  #.  Review of Patient 17's clinical record was initiated on 11/20/25.  The clinical record showed the SOC was 3/5/25.  The patient was certified for hospice services during the certification periods from 3/5/25 to 6/2/25, 6/3/25 to 8/31/25, 9/1/25 to 10/30/25 and 10/31/25 to 12/29/25. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/3, 9/17, 10/1, 10/15, 10/29 and 11/15/25 showed the patients current problem list.  The list included an evaluation of patient/family mental coping and emotional stability. Review of the Nursing Visit notes dated 9/29, 10/6, 10/13, 10/20 and 10/27 and 10/29/25 showed the SN had performed an assessment.  The assessment included a section for the patients spiritual, psychosocial, social and emotional status. However, the SN failed to follow the POC as the sections for the assessment of the patients spiritual, psychosocial, social and emotional were left blank.On 11/25/25 at 1445 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.  #.  Review of Patient 1's closed clinical record was initiated on 11/14/25.  The clinical record showed the SOC was 12/18/24.  The patient was certified for hospice services during the certification periods from 12/18/24 to 3/17/25, 3/18/25 to 6/15/25 and 6/16/25 to 8/2/25.  The patient passed away on 8/2/25. *The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 7/16/25 cited SN visit 1 time a week.  The POC included a wound care order. The order showed to "cleanse Stage 2 -3 scattered decub to sacrum with dermal cleanser, pat dry with gauze, apply Medi-honey then cover with Mepilex or Duoderm lite.  Change weekly and as needed if moist, soiled or dislodge.  Caregiver may provide care".Review of the Visit Note Report dated 7/22, 7/29/25 showed the RN 4 performed a wound assessment and treatment to the patients Stage 3 pressure injury to the sacrum.  The wound treatment showed "cleanse healing stage 2-3 decub to sacrum with soap and water.  Strict pressure relief.  May apply Medi-honey with repositioning and leave open to air".  However, the wound treatment provided was inconsistent with the POC.*The Physicians Order dated 6/1/25 showed a recertification order.  The order includes the Chaplain visits cited 1W1, 2Q2W2, 1Q3Wk3, 1Q2W2.Review of the closed clinical record showed a missed visit documentation of Chaplain 2 for Weeks 1, 2 and 3. However, there was no documented evidenced of the Chaplain visit was conducted on Week 5 (from 7/13 to 7/19/25) as ordered by the physician. On 11/25/25 at 1335 hours, an interview and concurrent closed clinical record review was conducted with the Administrator.  The Administrator was asked if it was a missed visit.  The Administrator reviewed the closed clinical record and replied, there should be a Chaplain visit on Week 5 but there was none. The Administrator was also asked if there was a communication note related to the Chaplain missed visit.  The Administrator replied, “We’ll look for the record.  The Administrator was further asked if the wound treatment was followed as ordered in the POC.  The Administrator reviewed the closed clinical record and replied, no.  The Administrator was informed and acknowledged the findings.  #.   Review of Patient 6's clinical record was initiated on 11/18/25.  The clinical record showed the SOC was 9/25/24.  The patient was certified for hospice services during the certification periods from 9/25/24 to 12/23/24, 12/24/24 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, 9/20/25 to 11/18/25 and 11/19/25 to 1/17/25.Review of the Physicians' Order dated 9/5/25. showed the recertification order.  The Order included a Chaplain visit one time per month for spiritual support.However, review of the clinical record failed to show documented evidenced of the Chaplain had visited the patient for the month of October as ordered. On 11/25/25 at 0909 hours an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was asked if there was a visit conducted by the Chaplain for the month of October.  The Administrator reviewed the clinical record and replied, no, it should be a PRN visit, it's a clinical error.  The Administrator was informed and acknowledged the findings.  #.   Review of Patient 5's clinical record was initiated on 11/13/25.  The clinical record showed the SOC was 3/13/25.  The patient was certified for hospice services during the certification periods from 3/13/25 to 6/10/25, 6/11/25 to 9/8/25, 9/9/25 to 11/7/25 and 11/8/25 to 1/6/26.The Physicians Order dated 9/15/25, showed a wound care order.  The order was for "nystatin 100,000 units /gram powder, apply to peri wound of sacral ulcer mix with Calmoseptine to be apply every dressing change for three weeks due to redness".Review of the Visit Note Report for example dated 9/17, 9/24, 9/26 and 10/1/25 on the section of narrative showed the SN had performed wound assessment and treatment to the patients pressure injury to the sacral coccyx area.   The treatment showed cleanse wound with wound cleanser patted dry apply tetracycline followed by Medihoney covered with alginate and foam dressing.  However, the SN failed to follow the physicians order for the treatment of the patients pressure injury to the sacral/coccyx area. On 11/26/25 at 0811 hours an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was asked if the wound care treatment for nystatin and calmoseptine was provided.  The Administrator reviewed the clinical record and replied, none documented.  The Administrator was informed and acknowledged the findings.   The hospice's P&P titled Plan of Care Process reviewed 9/1/24, showed to ensure that the care provided is in accordance with the written plan of care (POC), appropriately planned, and delivered in a timely manner to meet the patient's and family's specific needs. 1.  Review of Patient 15's clinical record was initiated on 11/20/25.  The clinical record showed the SOC was 9/9/24.  The patient was certified for hospice services during the certification periods from 9/9/24 to 12/7/24, 12/8/24 to 3/7/25, 3/8/25 to 5/6/25, 5/7/25 to 7/5/25, 7/6/25 to 9/3/25, 9/4/25 to 11/2/25, and 11/3/25 to 1/1/26. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/3, 9/17, 10/1, 10/15, and 10/29/25, showed the patient's current problem list.  The list included an evaluation of patient/family mental coping and emotional stability. Review of the Nursing Visit notes dated 9/26 and 10/22/25, showed RN 2 had performed an assessment.  The assessment included a section for the patient's spiritual, psychosocial, social, and emotional status. However, RN 2 failed to follow the POC as the assessment for the patient's spiritual, psychosocial, social and emotional were left blank. On 11/25/25 at 1524 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was asked if the SN needed to complete the assessment.  The Administrator stated yes.  The Administrator was also asked if the care plan was followed.  The Administrator reviewed the clinical record and acknowledged the findings. 2.  Review of Patient 11's clinical record was initiated on 11/18/25.  The clinical record showed the SOC was 2/18/25.  The patient was certified for hospice services during the certification periods from 2/18/25 to 5/18/25, 5/19/25 to 8/16/25, 8/17/25 to 10/15/25, and 10/16/25 to 12/14/25. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 8/20, 9/3, 9/17, 10/15, 10/29, and 11/15/25, showed the patient's current problem list.  The list included an evaluation of patient/family mental coping and emotional stability. Review of the Nursing Visit notes dated 10/7 and 10/29/25, showed the SN had performed an assessment.  The assessment included a section for the patients spiritual, psychosocial, social, and emotional status. However, RN 2 failed to follow the POC as the assessment for the patients spiritual, psychosocial, social and emotional were left blank. On 11/26/25 at 1030 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the finding.  3.  Review of Patient 17's clinical record was initiated on 11/20/25.  The clinical record showed the SOC was 3/5/25.  The patient was certified for hospice services during the certification periods from 3/5/25 to 6/2/25, 6/3/25 to 8/31/25, 9/1/25 to 10/30/25, and 10/31/25 to 12/29/25. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/3, 9/17, 10/1, 10/15, 10/29, and 11/15/25, showed the patient's current problem list.  The list included an evaluation of patient/family mental coping and emotional stability. Review of the Nursing Visit notes dated 9/29, 10/6, 10/13, 10/20, 10/27, and 10/29/25, showed the SN had performed an assessment.  The assessment included a section for the patients spiritual, psychosocial, social and emotional status. However, the SN failed to follow the POC as the sections for the assessment of the patient's spiritual, psychosocial, social and emotional were left blank.On 11/25/25 at 1445 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.  4.  Review of Patient 1's closed clinical record was initiated on 11/14/25.  The clinical record showed the SOC was 12/18/24.  The patient was certified for hospice services during the certification periods from 12/18/24 to 3/17/25, 3/18/25 to 6/15/25, and 6/16/25 to 8/2/25.  The patient expired on 8/2/25. *The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 7/16/25, cited SN visit one time a week.  The POC included a wound care order. The order showed to "cleanse Stage 2 -3 scattered decub to sacrum with dermal cleanser, pat dry with gauze, apply Medi-honey then cover with Mepilex or Duoderm lite.  Change weekly and as needed if moist, soiled or dislodge.  Caregiver may provide care."Review of the Visit Note Report dated 7/22 and 7/29/25, showed RN 4 performed a wound assessment and treatment to patient's Stage 3 sacrum pressure injury.  The wound treatment showed, "cleanse healing stage 2-3 decub to sacrum with soap and water.  Strict pressure relief.  May apply Medi-honey with repositioning and leave open to air."  However, the wound treatment provided was inconsistent with the POC.*The Physician's Order dated 6/1/25, showed the recertification order included Chaplain visits 1W1 (one time a week for one week), 2Q2W2 (two times every two weeks for two weeks), 1Q3W3, and 1Q2W2.Review of the closed clinical record showed a missed visit documentation of Chaplain 2 for Weeks 1, 2, and 3. However, there was no documented evidenced the Chaplain visit was conducted on Week 5 (7/13/25 to 7/19/25) as ordered by the physician. On 11/25/25 at 1335 hours, an interview and concurrent closed clinical record review was conducted with the Administrator.  The Administrator was asked if it was a missed visit.  The Administrator reviewed the closed clinical record and stated there should be a Chaplain visit for Week 5 but there was none. The Administrator was also asked if there was a communication note related to the Chaplain missed visit.  The Administrator replied, “We’ll look for the record."  The Administrator was further asked if the wound treatment was followed as ordered in the POC.  The Administrator reviewed the closed clinical record and stated no.  The Administrator was informed and acknowledged the findings.  5.   Review of Patient 6's clinical record was initiated on 11/18/25.  The clinical record showed the SOC was 9/25/24.  The patient was certified for hospice services during the certification periods from 9/25/24 to 12/23/24, 12/24/24 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, 9/20/25 to 11/18/25, and 11/19/25 to 1/17/25.Review of the Physicians' Order dated 9/5/25. showed the recertification order included a Chaplain visit one time per month for spiritual support.However, review of the clinical record failed to show documented evidence of Chaplain visited the patient for the month of October as ordered. On 11/25/25 at 0909 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was asked if there was a visit conducted by the Chaplain for the month of October.  The Administrator reviewed the clinical record and stated no, it should be a PRN visit, and it was a clinical error.  The Administrator was informed and acknowledged the findings. 6.   Review of Patient 5's clinical record was initiated on 11/13/25.  The clinical record showed the SOC was 3/13/25.  The patient was certified for hospice services during the certification periods from 3/13/25 to 6/10/25, 6/11/25 to 9/8/25, 9/9/25 to 11/7/25, and 11/8/25 to 1/6/26.The Physician's Order dated 9/15/25, showed a wound care order as follows: "nystatin 100,000 units /gram powder, apply to peri wound of sacral ulcer mix with Calmoseptine to be apply every dressing change for three weeks due to redness."Review of the Visit Note Report on the section of narrative dated 9/17, 9/24, 9/26, and 10/1/25,  showed the SN performed wound assessment and treatment to the patient's sacral coccyx area pressure injury.   Documentation showed the treatment included wound cleansed  with wound cleanser, patted dry, applied tetracycline (antibiotic), followed by Medihoney (used for wound care), and covered with alginate (wound dressing) and foam dressing.  However, the SN failed to follow the physician's order for the treatment of the patient's sacral/coccyx area pressure injury. On 11/26/25 at 0811 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was asked if the wound care treatment for nystatin (antifungal) and Calmoseptine (moisture barrier) were provided.  The Administrator reviewed the clinical record and stated there was none documented.  The Administrator was informed and acknowledged the findings. 7.  Review of Patient 16's clinical record was initiated on 11/12/25. The clinical record showed the SOC was 9/3/25. The patient was certified for hospice services during certification period 9/3/25 to 12/1/25.Review of the physician's order dated 9/5/25, showed an order for SN visits 2W1 and 2W8, effective 9/3/25.*However,  there was no documented SN visit for the week of 11/2/25 to 11/8/25.On 11/24/25 at 1304 hours, an interview and concurrent clinical record review was conducted with the DPCS.  The DPCS was asked if there was any documentation for Patient 16's SN visit for the week of 11/2/25 to 11/8/25.  The DPCS verified she could not find any SN visit documentation within that week.  The DPCS was further asked if there was any SN missed visit documentation and any documentation that offer of the SN visit within that week.  The DPCS verified it was missed visit.  The DPCS acknowledged she could not find any documentation of any SN visit or follow up visit that was offered.8. Review of Patient 3’s closed clinical record was initiated on 11/13/25. The clinical record showed the SOC was 1/25/24. The patient was certified for hospice during the certification periods from 1/25/24 to 4/23/24, 4/24/24 to 7/22/24, 6/14/24 to 8/12/24, 8/13/24 to 10/11/24, 10/12/24 to 12/10/24, 12/11/24 to 2/8/25, 2/9/25 to 4/9/25, and 4/10/25 to 6/2/25.  The patient expired on 6/2/25.Review of the physician’s order dated 3/26/25, showed an order for MSW visits 1W1 and 1Q2W2 effective 4/13/25*However, the MSW had no documented evidence of visits for the weeks 4/27/25 to 5/3/25, 5/4/25 to 5/10/25, and 5/11/25 to 5/17/25.On 11/13/25 at 1500 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator stated if the visit was missed for the week, a visit should have been rescheduled or offered a visit for the following week.  The Administrator verified and acknowledged the finding.9. Review of Patient 7’s clinical record was initiated on 11/18/25.  The clinical record showed the SOC was 7/27/24.  The patient was certified for hospice during the certification periods from 7/27/24 to 10/24/24, 10/25/24 to 1/22/25, 1/23/25 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, and 9/20/25 to 11/18/25.a.  Review of the physician’s order dated 10/27/25, showed an order for SN visits W1, 2W2, and 1W1, effective 10/26/25*However, the SN notes for Week 7 (10/26/25 to 11/1/25) showed two SN visits instead of three visits as per the physician’s order.b.  Review of the physician’s order dated 10/9/25, showed an order for MSW visits 1W3, effective 10/26/25*However, there was no documented evidence the MSW had visits for the weeks of 10/26/25 to 11/1/25, and 11/2/25 to 11/8/25.On 11/21/25 at 1343 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. The Administrator stated the missed visits were reported; however, there was no documented evidence the missed visits were offered for another day.  The Administrator and DPCS verified and acknowledged the findings.10. Review of Patient 13’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 1/12/23. The patient was certified for hospice during the certification periods from 1/12/23 to 4/11/23, 4/12/23 to 7/10/23, 7/11/23 to 9/8/23, 9/9/23 to 11/7/23, 11/8/23 to 1/6/24, 1/7/24 to 3/6/24, 3/7/24 to 5/5/24, 5/6/24 to 7/4/24, 7/5/24 to 9/2/24, 9/3/24 to 11/1/24, 11/2/24 to 12/31/24, 1/1/25 to 3/1/25, 3/2/25 to 4/30/25, 5/1/25 to 6/29/25, 6/30/25 to 8/28/25, 8/29/25 to 10/27/25, and 10/28/25 to 12/26/25.Review of the physician’s order dated 8/14/25, showed an order may recertify the patient for the next hospice certification period (8/29/25 to 10/27/25). Documentation showed the calendar frequency for the SN was 1W8 effective 8/31/25.Review of the calendar of actual visits for the SN for Week 7 (10/5/25 to 10/11/25) showed the SN had two visits which were on 10/7/25 and 10/8/25.Review of the RN Visit Note Report dated 10/8/25, showed the visit type was SN Hospice PRN visit.  Documentation showed the patient was found on the floor next to the bed on the right side and an unwitnessed fall.  Documentation showed on inspection a small bump on the right side of the forehead.  Documentation showed the physician was notified and a new order was received for a floor mat.*However, review of the physician’s order dated 10/8/25, failed to show an order for the PRN visit.On 11/21/25 at 1020 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. They both verified and acknowledged the findings.

Based on record review and interview, the hospice failed to ensure the written POCs were developed to reflect the patient and family goals and interventions based on the problems identified for six of 19 sampled patients (Patients 3, 5, 6, 7, 13, and 17).  This failure created the risk of not addressing the care needs for these patients.Findings: --- xx. Review of Patient 3’s closed clinical record was initiated on 11/13/25. The clinical record showed the SOC was 1/25/24. The patient was certified for hospice during the certification periods from 1/25/24 to 4/23/24, 4/24/24 to 7/22/24, 6/14/24 to 8/12/24, 8/13/24 to 10/11/24, 10/12/24 to 12/10/24, 12/11/24 to 2/8/25, 2/9/25 to 4/9/25 and 4/10/25 to 6/2/25. Patient expired on 6/2/25.a.Review of the RN Visit Note Report dated 5/2/25, showed in the narrative that patient stated she returned to bed as her buttocks was burning, applied calmoseptine (provide relief to skin irritants) to coccyx/buttocks for skin protection.The physician’s order dated 5/11/25, showed apply a thin layer of calmoseptine to buttocks two times a day for skin protection.*However, there was no documented evidence the IDG had developed an individualized POC to address Patient 3’s skin impairment.b.Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report showed a documentation that patient was found on the floor next to the bed on 5/20/21.*However, there was no documented evidence the IDG had developed an individualized POC to address Patient 3’s fall.c.Review of the of the RN Visit Note Report dated 5/30/25, showed in the narrative that patient appears to be transitioning, agitated and trying to get out of bed.*However, there was no documented evidence the IDG had developed an individualized POC to address Patient 3’s change of condition.On 11/21/25 at 0833 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator verified and acknowledged the findings.xx. Review of Patient 7’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 7/27/24. The patient was certified for hospice during the certification periods from 7/27/24 to 10/24/24, 10/25/24 to 1/22/25, 1/23/25 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25 and 9/20/25 to 11/18/25.a.Review of the RN Visit Note Report dated 10/20/25, showed in the narrative that patient reported occasional episodes of shortness of breath.  The physician’s order dated 10/21/25, showed the to administer oxygen at 2-5 liters per minute for shortness of breath via nasal cannula; and*However, there was no documented evidence the IDG had developed an individualized POC to address Patient 7’s shortness of breath.b.Review of the RN Visit Note Report dated 10/23/25, showed in the narrative that patient reported feeling more depressed than before.The physician’s order dated 10/23/25, showed an increase in Bupropion hydrochloride (medication used as an antidepressant) 150 mg 24 hour tablet to two times daily.Furthermore, the physician’s order dated 10/23/25, showed the changes in the following orders:-Diazepam (medication for relieving anxiety disorders) 5 mg tablet at bedtime for anti-anxiety;-melatonin (short-term aid for various sleep issues) 10 mg capsule at bedtime for sleeping aid.*However, there was no documented evidence the IDG had developed an individualized POC to address Patient 7’s problem related to depression, anxiety and sleeplessness.On 11/21/25 at 1343 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. The Administrator and DPCS verified and acknowledged the findings.xx. Review of Patient 13’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 1/12/23. The patient was certified for hospice during the certification periods from 1/12/23 to 4/11/23, 4/12/23 to 7/10/23, 7/11/23 to 9/8/23, 9/9/23 to 11/7/23, 11/8/23 to 1/6/24, 1/7/24 to 3/6/24, 3/7/24 to 5/5/24, 5/6/24 to 7/4/24, 7/5/24 to 9/2/24, 9/3/24 to 11/1/24, 11/2/24 to 12/31/24, 1/1/25 to 3/1/25, 3/2/25 to 4/30/25, 5/1/25 to 6/29/25, 6/30/25 to 8/28/25, 8/29/25 to 10/27/25 and 10/28/25 to 12/26/25.a.Review of the RN Visit Note Report dated 9/23/25 showed wound care was provided to Patient 13’s right nipple, cleansed wound with saline and patted dry. Right nipple exposed to air.*However, there was no documented evidence the IDG had developed an individualized POC to address Patient 13’s problem related to the wound in the right nipple.Review of the RN Visit Note Report dated 10/8/25, showed in the narrative patient was found on the floor next to the bed on the right side, an unwitnessed fall. On inspection small bump on the right side of forehead measuring 0.8 cm x 1.2 cm.Furthermore, review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 10/13/25, showed the recent fall on 10/8/25 was discussed in the IDG. However, in the plan of care updates/IDG recommendation, showed no plan of care updates.There was no documented evidence the IDG had developed an individualized POC to address Patient 13’s fall.On 11/21/25 at 1020 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. They both verified and acknowledged the findings. The hospice's P&P titled Plan of Care Process reviewed 9/1/24 showed the hospice will develop an individualized POC for each patient.  The POC must reflect patient and family goals and intervention based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. #.  Review of Patient 17's clinical record was initiated on 11/20/25.  The clinical record showed the SOC was 3/5/25.  The patient was certified for hospice services during the certification periods from 3/5/25 to 6/2/25, 6/3/25 to 8/31/25, 9/1/25 to 10/30/25 and 10/31/25 to 12/29/25. Review of the RN Hospice Recert Assessment dated 8/18/25, showed the RN 1 had performed an assessment.  The assessment showed the patients primary diagnosis of hypertensive heart disease.  The patient was assessed to have  + 2 edema to the left foot, ankle and calf. However, review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 8/20/25, failed to show documented evidenced of an individualized POC was developed to address the patients + 2 edema to the left foot, ankle and calf. Further review of the Visit Note Report on the following dates showed:-on 9/5 and 9/8/25 = +1 edema to the right and left foot and calf,  +2 edema to the right and left ankle,-on  9/11/25 = +1 edema to the right and left foot and calf,  +2 edema to the right and left ankle and +1 edema to the right and left thigh.However, review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/3 and 9/17/25 failed to show documented evidenced of an individualized POC was developed to address the patients edema to the bilateral lower extremities. On 11/25/25 at 1445 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was asked if a care plan was developed to address the patients edema.  The Administrator reviewed the clinical record and replied, no, was not develop.  The Administrator was informed and acknowledged the findings.  #.  Review of Patient 6's clinical record was initiated on 11/18/25.  The clinical record showed the SOC was 9/25/24.  The patient was certified for hospice services during the certification periods from 9/25/24 to 12/23/24, 12/24/24 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, 9/20/25 to 11/18/25 and 11/19/25 to 1/17/25. *Review of the Physicians Order dated 9/26/25, showed an order for Bactrim DS take one tablet BID for 7 days for UTI.Further review of the Physicians Order dated 10/6/25,  showed an order for Cephalexin 250 mg QD for prophylactic prevention of UTI.However, review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 10/1 and 10/15/25 failed to show documented evidenced of an individualized POC was developed to address the patients UTI. *Review of the Physicians Order dated 10/23/25,  showed an order for Seroquel 25 mg QHS for insomnia.However, review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 10/29/25 failed to show documented evidenced of an individualized POC was developed to address the patients insomnia. On 11/25/25 at 0909 hours an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was asked if a care plan was developed to address the patients UTI and insomnia.  The Administrator reviewed the clinical record and replied, no, was not develop.  The Administrator was informed and acknowledged the findings.  #.  Review of Patient 5's clinical record was initiated on 11/13/25.  The clinical record showed the SOC was 3/13/25.  The patient was certified for hospice services during the certification periods from 3/13/25 to 6/10/25, 6/11/25 to 9/8/25, 9/9/25 to 11/7/25 and 11/8/25 to 1/6/26.The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated  9/17, 10/1, 1015, 10/29 and 11/2/25 on the section of medication list showed the patient was on oral hypoglycemics and insulin injection.However, the IDG failed to developed an individualized care plan to address the patients diabetes. On 11/26/25 at 0811 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was asked if a care plan related to diabetes was developed.  The Administrator reviewed the clinical record and replied it was missed.  The Administrator was informed and acknowledged the findings.   The hospice's P&P titled Plan of Care Process reviewed 9/1/24, showed the hospice will develop an individualized POC for each patient.  The POC must reflect patient and family goals and intervention based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. 1.  Review of Patient 17's clinical record was initiated on 11/20/25.  The clinical record showed the SOC was 3/5/25.  The patient was certified for hospice services during the certification periods from 3/5/25 to 6/2/25, 6/3/25 to 8/31/25, 9/1/25 to 10/30/25, and 10/31/25 to 12/29/25. Review of the RN Hospice Recert Assessment dated 8/18/25, showed RN 1 had performed an assessment.  The assessment showed the patient's primary diagnosis of hypertensive heart disease.  The patient was assessed to have  2+ edema (scale to rate the severity of edema 0=no edema 4+=severe edema) on the left foot, ankle, and calf. However, review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 8/20/25, failed to show documented evidence of an individualized POC was developed to address the patients 2+ edema on the left foot, ankle, and calf. Further review of the Visit Note Report on the following dates showed:-On 9/5 and 9/8/25, 1+ edema on the right and left foot and calf and  2+ edema to the right and left ankle,-On 9/11/25,  1+ edema on the right and left foot and calf,  2+ edema to the right and left ankle, and 1+ edema on the right and left thigh.However, review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/3 and 9/17/25, failed to show documented evidence of an individualized POC was developed to address the patient's edema on the bilateral lower extremities. On 11/25/25 at 1445 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was asked if a care plan was developed to address the patient's edema.  The Administrator reviewed the clinical record and stated no and was not developed.  The Administrator was informed and acknowledged the findings. 2.  Review of Patient 6's clinical record was initiated on 11/18/25.  The clinical record showed the SOC was 9/25/24.  The patient was certified for hospice services during the certification periods from 9/25/24 to 12/23/24, 12/24/24 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, 9/20/25 to 11/18/25, and 11/19/25 to 1/17/25. *Review of the Physicians Order dated 9/26/25, showed an order for Bactrim DS (anitibiotic) one tablet BID for seven days for UTI.Further review of the Physicians Order dated 10/6/25, showed an order for cephalexin (antibiotic) 250 mg QD for prophylactic prevention of UTI.However, review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 10/1 and 10/15/25, failed to show documented evidenced of an individualized POC was developed to address the patient's UTI. *Review of the Physicians Order dated 10/23/25,  showed an order for Seroquel (antipsychotic) 25 mg QHS for insomnia.However, review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 10/29/25, failed to show documented evidenced of an individualized POC was developed to address the patient's insomnia. On 11/25/25 at 0909 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was asked if a care plan was developed to address the patient's UTI and insomnia.  The Administrator reviewed the clinical record and stated no and was not developed.  The Administrator was informed and acknowledged the findings. 3.  Review of Patient 5's clinical record was initiated on 11/13/25.  The clinical record showed the SOC was 3/13/25.  The patient was certified for hospice services during the certification periods from 3/13/25 to 6/10/25, 6/11/25 to 9/8/25, 9/9/25 to 11/7/25, and 11/8/25 to 1/6/26.The Hospice IDG Comprehensive Assessment and Plan of Care Update Report on the section of medication list dated 9/17, 10/1, 10/15, 10/29, and 11/2/25 showed the patient was on oral hypoglycemics and insulin injection.However, the IDG failed to developed an individualized care plan to address the patient's diabetes. On 11/26/25 at 0811 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was asked if a care plan related to diabetes was developed.  The Administrator reviewed the clinical record and stated it was missed.  The Administrator was informed and acknowledged the findings.  4. Review of Patient 3’s closed clinical record was initiated on 11/13/25. The clinical record showed the SOC was 1/25/24. The patient was certified for hospice during the certification periods from 1/25/24 to 4/23/24, 4/24/24 to 7/22/24, 6/14/24 to 8/12/24, 8/13/24 to 10/11/24, 10/12/24 to 12/10/24, 12/11/24 to 2/8/25, 2/9/25 to 4/9/25, and 4/10/25 to 6/2/25. Patient expired on 6/2/25.a. Review of the RN Visit Note Report dated 5/2/25, showed the patient stated she returned to bed as her buttocks was burning, applied Calmoseptine (moisture barrier) to the coccyx/buttocks for skin protection.The physician’s order dated 5/11/25, showed to apply a thin layer of Calmoseptine to buttocks two times a day for skin protection.*However, there was no documented evidence the IDG had developed an individualized POC to address Patient 3’s skin impairment.b.Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 5/21/25, showed a documentation the patient was found on the floor next to the bed on "5/20."*However, there was no documented evidence the IDG had developed an individualized POC to address Patient 3’s fall.c. Review of the of the RN Visit Note Report dated 5/30/25, showed the patient appeared to be transitioning, agitated, and trying to get out of bed.*However, there was no documented evidence the IDG had developed an individualized POC to address Patient 3’s change of condition.On 11/21/25 at 0833 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator verified and acknowledged the findings.5. Review of Patient 7’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 7/27/24. The patient was certified for hospice during the certification periods from 7/27/24 to 10/24/24, 10/25/24 to 1/22/25, 1/23/25 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, and 9/20/25 to 11/18/25.a. Review of the RN Visit Note Report dated 10/20/25, showed the patient reported occasional episodes of shortness of breath.  The physician’s order dated 10/21/25, showed to administer oxygen at 2-5 liters per minute for shortness of breath via nasal cannula.*However, there was no documented evidence the IDG had developed an individualized POC to address Patient 7’s shortness of breath.b. Review of the RN Visit Note Report dated 10/23/25, showed in the narrative that patient reported feeling more depressed than before.The physician’s order dated 10/23/25, showed an increase in Bupropion hydrochloride (medication used as an antidepressant) 150 mg 24 hour tablet to two times daily.Furthermore, the physician’s order dated 10/23/25, showed the changes in the following orders:-Diazepam (medication for relieving anxiety disorders) 5 mg tablet at bedtime for anti-anxiety;-melatonin (short-term aid for various sleep issues) 10 mg capsule at bedtime for sleeping aid.*However, there was no documented evidence the IDG had developed an individualized POC to address Patient 7’s problem related to depression, anxiety and sleeplessness.On 11/21/25 at 1343 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. The Administrator and DPCS verified and acknowledged the findings.6. Review of Patient 13’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 1/12/23. The patient was certified for hospice during the certification periods from 1/12/23 to 4/11/23, 4/12/23 to 7/10/23, 7/11/23 to 9/8/23, 9/9/23 to 11/7/23, 11/8/23 to 1/6/24, 1/7/24 to 3/6/24, 3/7/24 to 5/5/24, 5/6/24 to 7/4/24, 7/5/24 to 9/2/24, 9/3/24 to 11/1/24, 11/2/24 to 12/31/24, 1/1/25 to 3/1/25, 3/2/25 to 4/30/25, 5/1/25 to 6/29/25, 6/30/25 to 8/28/25, 8/29/25 to 10/27/25 and 10/28/25 to 12/26/25.a. Review of the RN Visit Note Report dated 9/23/25 showed wound care was provided to Patient 13’s right nipple, cleansed wound with saline and patted dry. Right nipple exposed to air.*However, there was no documented evidence the IDG had developed an individualized POC to address Patient 13’s problem related to the wound in the right nipple.Review of the RN Visit Note Report dated 10/8/25, showed in the narrative patient was found on the floor next to the bed on the right side, an unwitnessed fall. On inspection small bump on the right side of forehead measuring 0.8 cm x 1.2 cm.Furthermore, review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 10/13/25, showed the recent fall on 10/8/25 was discussed in the IDG. However, in the plan of care updates/IDG recommendation, showed no plan of care updates.There was no documented evidence the IDG had developed an individualized POC to address Patient 13’s fall.On 11/21/25 at 1020 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. They both verified and acknowledged the findings.

Based on record review and interview, the hospice failed to ensure the POCs included measurable outcome for 12 of 19 sampled patients (Patients 1, 3, 4, 5, 6, 7, 9, 11,13, 14, 15 and 17). This failure had the potential risk of not evaluating the POC and providing appropriate care and services to these patients.Findings: --- #.Review of Patient 3’s closed clinical record was initiated on 11/13/25. The clinical record showed the SOC was 1/25/24. The patient was certified for hospice during the certification periods from 1/25/24 to 4/23/24, 4/24/24 to 7/22/24, 6/14/24 to 8/12/24, 8/13/24 to 10/11/24, 10/12/24 to 12/10/24, 12/11/24 to 2/8/25, 2/9/25 to 4/9/25 and 4/10/25 to 6/2/25. Patient expired on 6/2/25.The Hospice POC Report, showed the patient’s identified problems. The goal was established for the identified problem. However, the goal listed was not measurable and specific to the patient’s needs.For example, the goal for altered cardiac/circulatory system was that cardiac exacerbations are identified promptly and interventions initiated. However, there was no documented evidence of the measurable outcome as to what cardiac exacerbations would be related to the cardiac/circulatory system.Another example was the goal for altered comfort was that patient verbalizes decrease in pain or has decrease in non-verbal signs and symptoms of pain. However, there was no documented evidence of the measurable outcome as to what non-verbal signs and symptoms of pain would be related to altered comfort.On 11/21/25 at 0833 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator verified and acknowledged the findings.xx.Review of Patient 4’s closed clinical record was initiated on 11/14/25. The clinical record showed the SOC was 12/23/24. The patient was certified for hospice services during the certification period 12/23/24 to 3/22/25, The patient was discharged from hospice service on 2/4/25.The Hospice POC Report, showed the patient’s identified problems. The goal was established for the identified problem. However, the goal listed was not measurable and specific to the patient’s needs.a.The goal for need for observation and assessment of altered comfort was that patient verbalizes decrease in pain or has decrease in non-verbal signs and symptoms of pain. However, there was no documented evidence of the measurable outcome as to what non-verbal signs and symptoms of pain would be related to altered comfort.b.The goal for need for observation and assessment of sensory/neurological status was that patient tolerates assessment of sensory/neurological status. However, there was no documented evidence of the measurable outcome as to what kind of assessment would be tolerated by the patient related to sensory/neurological status.c.The goal for altered home safety was the patient/caregiver verbalizes understanding of proper safety measures related to fall awareness. However, there was no documented evidence as to what proper safety measures were related to home safety.On 11/21/25 at 1114 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. They both verified and acknowledged the findings.xx. Review of Patient 7’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 7/27/24. The patient was certified for hospice during the certification periods from 7/27/24 to 10/24/24, 10/25/24 to 1/22/25, 1/23/25 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25 and 9/20/25 to 11/18/25.The Hospice POC Report, showed the patient’s identified problems. The goal was established for the identified problem. However, the goal listed was not measurable and specific to the patient’s needs.For example, the goal for need for observation and assessment of cardiac/circulatory system was that cardiac exacerbations are identified promptly and interventions initiated. However, there was no documented evidence of the measurable outcome as to what cardiac exacerbations would be related to the cardiac/circulatory system.On 11/21/25 at 1343 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. The Administrator and DPCS verified and acknowledged the findings.xx. Review of Patient 13’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 1/12/23. The patient was certified for hospice during the certification periods from 1/12/23 to 4/11/23, 4/12/23 to 7/10/23, 7/11/23 to 9/8/23, 9/9/23 to 11/7/23, 11/8/23 to 1/6/24, 1/7/24 to 3/6/24, 3/7/24 to 5/5/24, 5/6/24 to 7/4/24, 7/5/24 to 9/2/24, 9/3/24 to 11/1/24, 11/2/24 to 12/31/24, 1/1/25 to 3/1/25, 3/2/25 to 4/30/25, 5/1/25 to 6/29/25, 6/30/25 to 8/28/25, 8/29/25 to 10/27/25 and 10/28/25 to 12/26/25.The Hospice POC Report, showed the patient’s identified problems. The goal was established for the identified problem. However, the goal listed was not measurable and specific to the patient’s needs.For example, the goal for observation and assessment of skin was patient will be free from exacerbations of integumentary status. However, there was no documented evidence of the measurable outcome as to what exacerbations would be related to integumentary status.Another example would be the goal altered home safety was patient/caregivers verbalizes understanding of proper safety measures related to fall awareness. However, there was no documented evidence of the measurable outcome as to what safety measures are in relation to fall awareness.  On 11/21/25 at 1020 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. They both verified and acknowledged the findings.xx. Review of Patient 14’s clinical record was initiated on 11/19/25. The clinical record showed the SOC was 8/1/24. The patient was certified for hospice during the certification periods from 8/1/24 to 10/29/24, 10/30/24 to 12/28/24, 12/29/24 to 2/26/25, 2/27/25 to 4/27/25, 4/28/25 to 6/26/25, 6/27/25 to 8/25/25, 8/26/25 to 10/24/25 and 10/25/25 to 12/23/25.The Hospice POC Report, showed the patient’s identified problems. The goal was established for the identified problem. However, the goal listed was not measurable and specific to the patient’s needs.For example, the goal for observation and assessment of altered comfort was patient will verbalize decreased in pain or has decreased non-verbal signs and symptoms of pain as a result of pharmacologic pain control regimen. However, there was no documented evidence of the measurable outcome of what the non-verbal signs and symptoms of pain are in relation to patient’s altered comfort.For example, the goal for need for observation and assessment of cardiac/circulatory system was that cardiac exacerbations are identified promptly and interventions initiated. However, there was no documented evidence of the measurable outcome as to what cardiac exacerbations would be related to the cardiac/circulatory system.On 11/21/25 at 1425 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. They both verified and acknowledged the findings. The hospice's P&P titled Plan of Care Process reviewed 9/1/24 showed to ensure that the care provided is in accordance with the written plan of care (POC), appropriately planned, and delivered in a timely manner to meet the patients 's and family's specific needs. The POC incudes, but not limited to measurable outcomes anticipated from implementing and coordinating the POC.  Review of the clinical records for Patients 1, 3, 4, 5, 6, 7, 9, 11, 13,14, 15 and 17  showed no documented evidence the POCs included measurable outcomes.  For example:1. Review of Patient 15's clinical record was initiated on 11/20/25.  The clinical record showed the SOC was 9/9/24.  The patient was certified for hospice services during the certification periods from 9/9/24 to 12/7/24, 12/8/24 to 3/7/25, 3/8/25 to 5/6/25, 5/7/25 to 7/5/25, 7/6/25 to 9/3/25, 9/4/25 to 11/2/25 and 11/3/25 to 1/1/26. The Hospice POC Report, showed the patient’s identified problems. The goal was established for the identified problem. However, the goal listed was not measurable and specific to the patient’s needs for example:-the goal for altered comfort was that patient verbalizes decrease in pain or has decrease in non-verbal signs and symptoms of pain and verbalizes adequate pain control.  However, there was no documented evidence of the measurable outcome as to what an adequate and non-verbal signs and symptoms of pain would be related to altered comfort.-the goal for altered cardiac/circulatory system was that cardiac exacerbations are identified promptly and interventions initiated. However, there was no documented evidence of the measurable outcome as to what cardiac exacerbations would be related to the cardiac/circulatory system.-the goal for altered respiratory status was to verbalize comfort with respiratory status. However, there was no documented evidence of the measurable outcome as to what a comfortable respiratory status.-the goal for altered gastrointestinal status and constipation related to opioid use and or other GI problem was for the control of patients constipation, verbalizes proper nutrition and fluid intake to maintain proper bowel management.  However, there was no documented evidence of the measurable outcome as to what a controlled constipation, proper nutrition and proper bowel management was.On 11/25/25 at 1518 hours an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the IDG had reviewed/revised the patients’ POCs no less frequently than every 15 calendar days for three of 19 sampled patients (Patients 4, 9, and 17).  This failure had the potential for not providing appropriate, consistent, and quality care to these patients.Findings: --- The hospice’s P&P titled Interdisciplinary Group Roles and Responsibilities last reviewed 9/1/24 showed the IDG/IDT meetings will be held during the course of patient care to monitor and evaluate the patient’s interdisciplinary POC progress, at least every 15 days , or more frequently warranted by the patient’s condition.xx.Review of Patient 4’s closed clinical record was initiated on 11/14/25. The clinical record showed the SOC was 12/23/24. The patient was certified for hospice services during the certification period 12/23/24 to 3/22/25, The patient was discharged from hospice service on 2/4/25.Review of the clinical record showed the POC/IDG was conducted on 12/30/24 and 1/13/25.However, the following POC/IDG was conducted on 1/29/25, which was more than 15 calendar days as per the hospice’s P&P.On 11/21/25 at 1114 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. They both verified and acknowledged the findings. The hospice's P&P titled Plan of Care Process reviewed 9/1/24 showed the hospice will review and revise patient care in accordance with the changes in the patients response to care and changes that have occurred regarding diagnosis, treatment, medications, precautions and limitations. #.   Review of Patient 17's clinical record was initiated on 11/20/25.  The clinical record showed the SOC was 3/5/25.  The patient was certified for hospice services during the certification periods from 3/5/25 to 6/2/25, 6/3/25 to 8/31/25, 9/1/25 to 10/30/25 and 10/31/25 to 12/29/25. Review of the RN Hospice Recert Assessment dated 8/18/25, showed the RN 1 had performed an assessment.  The assessment showed the patients primary diagnosis of hypertensive heart disease.  The patient was assessed to have  + 2 edema to the left foot, ankle and calf. However, review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 8/20/25, failed to show documented evidenced of the IDG had reviewed/revised the POC to address the patients + 2 edema to the left foot, ankle and calf.  Further review of the Visit Note Report on the following dates showed:-on 9/5 and 9/8/25 = +1 edema to the right and left foot and calf,  +2 edema to the right and left ankle,-on  9/11/25 = +1 edema to the right and left foot and calf,  +2 edema to the right and left ankle and +1 edema to the right and left thigh.However, review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/3 and 9/17/25 failed to show documented evidenced of the IDG had reviewed/revised the POC to address the the patients edema to the bilateral lower extremities. On 11/25/25 at 1445 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was asked if the patients edema was discussed in the IDG.  The Administrator reviewed the clinical record and replied, no, was not discussed and updated.  The Administrator was informed and acknowledged the findings.             crossed ref. L-545 #. Review of Patient 9's clinical record was initiated on 11/19/25.  The clinical record showed the SOC was 1/14/25.  The patient was certified for hospice services during the certification periods from 1/14/25 to 4/13/25, 4/14/25 to 6/12/25, 6/13/25 to 8/11/25, 8/12/25 to 10/10/25 and 10/11/25 to 12/925.Review of the Visit Note Report dated 9/16/25, on the section of narrative to address significant changes in condition showed the PCG reported the patient passing out pebble like stools. MD made aware and received a new orders to increase Colace 250 mg BID and Senna 8.6 mg BID. Hold for loose stools.However, review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/17/25 failed to show documented evidenced of the IDG had reviewed and revised the care plan to address the patients episode of passing out of pebble stools. Moreover, there was no documented evidence of the IDG discussed the new orders to increase Colace 250 mg BID and Senna 8.6 mg BID as written on the SN visit notes. On 11/26/25 at 0958 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was asked if the patients stool softeners/medications were discussed in the IDG.  The Administrator reviewed the clinical record and replied, the MD ordered date for the medications was 9/18/25, hence it was not discussed on 9/17 IDG but on 10/1/25 IDG.  The Administrator was also asked if the POC/IDG dated 9/17/25 was revised to show the episode of the reported passing out of pebble like stools.  The Administrator reviewed the clinical records and replied no.  The Administrator was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the revised POCs included the patients’ progress towards goals specified in the POCs for five of 19 sampled patients (Patients 3, 4, 7, 13, and 14).  This failure created the risk of not providing the necessary care and services to meet the care needs for these patients.Findings: --- 1.  Review of Patient 3’s closed clinical record was initiated on 11/13/25.  The clinical record showed the SOC was 1/25/24.  The patient was certified for hospice services during the certification periods from 1/25/24 to 4/23/24, 4/24/24 to 7/22/24, 6/14/24 to 8/12/24, 8/13/24 to 10/11/24, 10/12/24 to 12/10/24, 12/11/24 to 2/8/25, 2/9/25 to 4/9/25, and 4/10/25 to 6/2/25.  The patient expired on 6/2/25. The Hospice POC Report showed the patient’s identified problems.  For example:-On 1/25/24, a care plan problem was added for observation and assessment of cardiac/circulatory system.-On 8/6/24, a care plan problem was added for altered comfort. Both care plan problem goals were established for the identified problems.  However, there was no documented evidence the revised POC included the patient’s progress towards the goal for the care plan problem identified. On 11/21/25 at 0833 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was informed and verified the finding. 2.  Review of Patient 4’s closed clinical record was initiated on 11/14/25.  The clinical record showed the SOC was 12/23/24.  The patient was certified for hospice services during the certification period 12/23/24 to 3/22/25.  The patient was discharged from hospice on 2/4/25. The Hospice POC Report showed the patient’s identified problems.  For example:-On 12/23/24, a care plan problem was added for observation and assessment of altered comfort and observation and assessment of sensory/neurological status.-On 12/25/24, a care plan problem was added for altered home safety.The care plan problem goals were established for the identified problems.  However, there was no documented evidence the revised POC included the patient’s progress towards the goal for the care plan problem identified. On 11/21/25 at 1114 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS.  They were informed and verified the finding. 3.  Review of Patient 7’s clinical record was initiated on 11/18/25.  The clinical record showed the SOC was 7/27/24.  The patient was certified for hospice services during the certification periods from 7/27/24 to 10/24/24, 10/25/24 to 1/22/25, 1/23/25 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, and 9/20/25 to 11/18/25. The Hospice POC Report, showed the patient’s identified problems. For example:-On 7/24/24, a care plan problem was added for a need for observation and assessment of cardiac/circulatory system.-On 7/27/24, a care plan problem was added for a need to assessment of nutrition/hydration.The care plan problem’s goals were established for the identified problems.  However, there was no documented evidence the revised POC included the patient’s progress towards the goal for the care plan problem identified. On 11/21/25 at 1343 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS.  They were informed and verified the finding. 4.  Review of Patient 13’s clinical record was initiated on 11/18/25.  The clinical record showed the SOC was 1/12/23.  The patient was certified for hospice services during the certification periods from 1/12/23 to 4/11/23, 4/12/23 to 7/10/23, 7/11/23 to 9/8/23, 9/9/23 to 11/7/23, 11/8/23 to 1/6/24, 1/7/24 to 3/6/24, 3/7/24 to 5/5/24, 5/6/24 to 7/4/24, 7/5/24 to 9/2/24, 9/3/24 to 11/1/24, 11/2/24 to 12/31/24, 1/1/25 to 3/1/25, 3/2/25 to 4/30/25, 5/1/25 to 6/29/25, 6/30/25 to 8/28/25, 8/29/25 to 10/27/25, and 10/28/25 to 12/26/25. The Hospice POC Report, showed the patient’s identified problems.  For example:-On 1/12/23, a care plan problem was added for altered home safety.-On 1/11/24, a care plan problem was added for observation and assessment of skin.The care plan problem’s goals were established for the identified problems.  However, there was no documented evidence the revised POC included the patient’s progress towards the goal for the care plan problem identified. On 11/21/25 at 1020 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS.  They were informed and verified the finding. 5.  Review of Patient 14’s clinical record was initiated on 11/19/25.  The clinical record showed the SOC was 8/1/24.  The patient was certified for hospice services during the certification periods from 8/1/24 to 10/29/24, 10/30/24 to 12/28/24, 12/29/24 to 2/26/25, 2/27/25 to 4/27/25, 4/28/25 to 6/26/25, 6/27/25 to 8/25/25, 8/26/25 to 10/24/25, and 10/25/25 to 12/23/25. The Hospice POC Report, showed the patient’s identified problems.  For example:-On 8/1/24, a care plan problem was added for observation and assessment of altered comfort.-On 8/1/24, a care plan problem was added for observation and assessment of cardiac/circulatory system.The care plan problem’s goals were established for the identified problems.  However, there was no documented evidence the revised POC included the patient’s progress towards the goal for the care plan problem identified. On 11/21/25 at 1425 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS.  They were informed and verified the finding.

Based on interview and record review, the hospice failed to ensure the IDG maintained the responsibility for directing and supervising the care and services provided for two of 19 sampled patients (Patients 1 and 13).  This failure created the risk of not addressing the care needs for these patients.Findings: --- Review of the hospice’s P&P titled Interdisciplinary Group Roles and Responsibilities last reviewed 9/1/24, showed the IDG/IDT responsibilities will include but not limited to:a.  Participation in the establishment of the plan of care with the patient and/or family and the primary physician;b  .Provision and supervision of hospice care and continuity of services;c.  Periodic reviews and updates of the plan of care for each patient receiving hospice care.xx.  Review of Patient 13’s clinical record was initiated on 11/18/25.  The clinical record showed the SOC was 1/12/23.  The patient was certified for hospice during the certification periods from 1/12/23 to 4/11/23, 4/12/23 to 7/10/23, 7/11/23 to 9/8/23, 9/9/23 to 11/7/23, 11/8/23 to 1/6/24, 1/7/24 to 3/6/24, 3/7/24 to 5/5/24, 5/6/24 to 7/4/24, 7/5/24 to 9/2/24, 9/3/24 to 11/1/24, 11/2/24 to 12/31/24, 1/1/25 to 3/1/25, 3/2/25 to 4/30/25, 5/1/25 to 6/29/25, 6/30/25 to 8/28/25, 8/29/25 to 10/27/25, and 10/28/25 to 12/26/25. Review of the SN Visit Note Report dated 9/23/25, showed a wound care was provided to Patient 13’s right nipple.  The wound was cleansed with saline and patted dry.  However, there was no documented evidence to show the patient’s status was reported to the physician. On 11/21/25 at 1020 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS.  They were informed and verified the finding. #.  Review of Patient 1's closed clinical record was initiated on 11/14/25.  The clinical record showed the SOC was 12/18/24.  The patient was certified for hospice services during the certification periods from 12/18/24 to 3/17/25, 3/18/25  to 6/15/25 and 6/16/25 to 8/2/25.  The patient passed away on 8/2/25. Review of the RN Hospice Start of Care dated 12/18/24, showed the RN 3 had performed an assessment. The assessment included a question for Volunteer needs. The question was " Is the patient /caregiver open to Volunteer services to meet social /family support need".  The RN 1 documented "yes, Volunteer coordinator notified of request".  The reason for the Volunteer services was for errands and emotional support (telephone).However, review of the closed clinical record failed to show documented evidenced of the request for the Volunteer services was coordinated with the Volunteer Coordinator. On 11/25/25 at 1135 hours, an interview and concurrent closed clinical record review was conducted with the Administrator.  The Administrator was asked if the Volunteer visit was conducted.  The Administrator reviewed the closed clinical record and replied, typically the Social Worker will follow up for the volunteer request, MSW saw the patient on 12/20/24 but does not document the need for Volunteer, we don't have Volunteer at that time.  The Administrator was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POC for 10 of 19 sampled patients (Patients 1, 3, 5, 6, 7, 11, 13, 15, 16, and 17).  This failure created the risk of not providing appropriate, consistent, and quality care to the patients. Findings: --- The hospice's P&P titled Plan of Care Process reviewed 9/1/24, showed to ensure that the care provided is in accordance with the written plan of care (POC), appropriately planned, and delivered in a timely manner to meet the patient's and family's specific needs. 1.  Review of Patient 15's clinical record was initiated on 11/20/25.  The clinical record showed the SOC was 9/9/24.  The patient was certified for hospice services during the certification periods from 9/9/24 to 12/7/24, 12/8/24 to 3/7/25, 3/8/25 to 5/6/25, 5/7/25 to 7/5/25, 7/6/25 to 9/3/25, 9/4/25 to 11/2/25, and 11/3/25 to 1/1/26. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/3, 9/17, 10/1, 10/15, and 10/29/25, showed the patient's current problem list.  The list included an evaluation of patient/family mental coping and emotional stability. Review of the Nursing Visit notes dated 9/26 and 10/22/25, showed RN 2 had performed an assessment.  The assessment included a section for the patient's spiritual, psychosocial, social, and emotional status. However, RN 2 failed to follow the POC as the assessment for the patient's spiritual, psychosocial, social and emotional were left blank. On 11/25/25 at 1524 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was asked if the SN needed to complete the assessment.  The Administrator stated yes.  The Administrator was also asked if the care plan was followed.  The Administrator reviewed the clinical record and acknowledged the findings. 2.  Review of Patient 11's clinical record was initiated on 11/18/25.  The clinical record showed the SOC was 2/18/25.  The patient was certified for hospice services during the certification periods from 2/18/25 to 5/18/25, 5/19/25 to 8/16/25, 8/17/25 to 10/15/25, and 10/16/25 to 12/14/25. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 8/20, 9/3, 9/17, 10/15, 10/29, and 11/15/25, showed the patient's current problem list.  The list included an evaluation of patient/family mental coping and emotional stability. Review of the Nursing Visit notes dated 10/7 and 10/29/25, showed the SN had performed an assessment.  The assessment included a section for the patients spiritual, psychosocial, social, and emotional status. However, RN 2 failed to follow the POC as the assessment for the patients spiritual, psychosocial, social and emotional were left blank. On 11/26/25 at 1030 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the finding.  3.  Review of Patient 17's clinical record was initiated on 11/20/25.  The clinical record showed the SOC was 3/5/25.  The patient was certified for hospice services during the certification periods from 3/5/25 to 6/2/25, 6/3/25 to 8/31/25, 9/1/25 to 10/30/25, and 10/31/25 to 12/29/25. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/3, 9/17, 10/1, 10/15, 10/29, and 11/15/25, showed the patient's current problem list.  The list included an evaluation of patient/family mental coping and emotional stability. Review of the Nursing Visit notes dated 9/29, 10/6, 10/13, 10/20, 10/27, and 10/29/25, showed the SN had performed an assessment.  The assessment included a section for the patients spiritual, psychosocial, social and emotional status. However, the SN failed to follow the POC as the sections for the assessment of the patient's spiritual, psychosocial, social and emotional were left blank.On 11/25/25 at 1445 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.  4.  Review of Patient 1's closed clinical record was initiated on 11/14/25.  The clinical record showed the SOC was 12/18/24.  The patient was certified for hospice services during the certification periods from 12/18/24 to 3/17/25, 3/18/25 to 6/15/25, and 6/16/25 to 8/2/25.  The patient expired on 8/2/25. *The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 7/16/25, cited SN visit one time a week.  The POC included a wound care order. The order showed to "cleanse Stage 2 -3 scattered decub to sacrum with dermal cleanser, pat dry with gauze, apply Medi-honey then cover with Mepilex or Duoderm lite.  Change weekly and as needed if moist, soiled or dislodge.  Caregiver may provide care."Review of the Visit Note Report dated 7/22 and 7/29/25, showed RN 4 performed a wound assessment and treatment to patient's Stage 3 sacrum pressure injury.  The wound treatment showed, "cleanse healing stage 2-3 decub to sacrum with soap and water.  Strict pressure relief.  May apply Medi-honey with repositioning and leave open to air."  However, the wound treatment provided was inconsistent with the POC.*The Physician's Order dated 6/1/25, showed the recertification order included Chaplain visits 1W1 (one time a week for one week), 2Q2W2 (two times every two weeks for two weeks), 1Q3W3, and 1Q2W2.Review of the closed clinical record showed a missed visit documentation of Chaplain 2 for Weeks 1, 2, and 3. However, there was no documented evidenced the Chaplain visit was conducted on Week 5 (7/13/25 to 7/19/25) as ordered by the physician. On 11/25/25 at 1335 hours, an interview and concurrent closed clinical record review was conducted with the Administrator.  The Administrator was asked if it was a missed visit.  The Administrator reviewed the closed clinical record and stated there should be a Chaplain visit for Week 5 but there was none. The Administrator was also asked if there was a communication note related to the Chaplain missed visit.  The Administrator replied, “We’ll look for the record."  The Administrator was further asked if the wound treatment was followed as ordered in the POC.  The Administrator reviewed the closed clinical record and stated no.  The Administrator was informed and acknowledged the findings.  5.   Review of Patient 6's clinical record was initiated on 11/18/25.  The clinical record showed the SOC was 9/25/24.  The patient was certified for hospice services during the certification periods from 9/25/24 to 12/23/24, 12/24/24 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, 9/20/25 to 11/18/25, and 11/19/25 to 1/17/25.Review of the Physicians' Order dated 9/5/25. showed the recertification order included a Chaplain visit one time per month for spiritual support.However, review of the clinical record failed to show documented evidence of Chaplain visited the patient for the month of October as ordered. On 11/25/25 at 0909 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was asked if there was a visit conducted by the Chaplain for the month of October.  The Administrator reviewed the clinical record and stated no, it should be a PRN visit, and it was a clinical error.  The Administrator was informed and acknowledged the findings. 6.   Review of Patient 5's clinical record was initiated on 11/13/25.  The clinical record showed the SOC was 3/13/25.  The patient was certified for hospice services during the certification periods from 3/13/25 to 6/10/25, 6/11/25 to 9/8/25, 9/9/25 to 11/7/25, and 11/8/25 to 1/6/26.The Physician's Order dated 9/15/25, showed a wound care order as follows: "nystatin 100,000 units /gram powder, apply to peri wound of sacral ulcer mix with Calmoseptine to be apply every dressing change for three weeks due to redness."Review of the Visit Note Report on the section of narrative dated 9/17, 9/24, 9/26, and 10/1/25,  showed the SN performed wound assessment and treatment to the patient's sacral coccyx area pressure injury.   Documentation showed the treatment included wound cleansed  with wound cleanser, patted dry, applied tetracycline (antibiotic), followed by Medihoney (used for wound care), and covered with alginate (wound dressing) and foam dressing.  However, the SN failed to follow the physician's order for the treatment of the patient's sacral/coccyx area pressure injury. On 11/26/25 at 0811 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was asked if the wound care treatment for nystatin (antifungal) and Calmoseptine (moisture barrier) were provided.  The Administrator reviewed the clinical record and stated there was none documented.  The Administrator was informed and acknowledged the findings. 7.  Review of Patient 16's clinical record was initiated on 11/12/25. The clinical record showed the SOC was 9/3/25. The patient was certified for hospice services during certification period 9/3/25 to 12/1/25.Review of the physician's order dated 9/5/25, showed an order for SN visits 2W1 and 2W8, effective 9/3/25.*However,  there was no documented SN visit for the week of 11/2/25 to 11/8/25.On 11/24/25 at 1304 hours, an interview and concurrent clinical record review was conducted with the DPCS.  The DPCS was asked if there was any documentation for Patient 16's SN visit for the week of 11/2/25 to 11/8/25.  The DPCS verified she could not find any SN visit documentation within that week.  The DPCS was further asked if there was any SN missed visit documentation and any documentation that offer of the SN visit within that week.  The DPCS verified it was missed visit.  The DPCS acknowledged she could not find any documentation of any SN visit or follow up visit that was offered.8. Review of Patient 3’s closed clinical record was initiated on 11/13/25. The clinical record showed the SOC was 1/25/24. The patient was certified for hospice services during the certification periods from 1/25/24 to 4/23/24, 4/24/24 to 7/22/24, 6/14/24 to 8/12/24, 8/13/24 to 10/11/24, 10/12/24 to 12/10/24, 12/11/24 to 2/8/25, 2/9/25 to 4/9/25, and 4/10/25 to 6/2/25.  The patient expired on 6/2/25.Review of the physician’s order dated 3/26/25, showed an order for MSW visits 1W1 and 1Q2W2 effective 4/13/25*However, the MSW had no documented evidence of visits for the weeks 4/27/25 to 5/3/25, 5/4/25 to 5/10/25, and 5/11/25 to 5/17/25.On 11/13/25 at 1500 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator stated if the visit was missed for the week, a visit should have been rescheduled or offered a visit for the following week.  The Administrator verified and acknowledged the finding.9. Review of Patient 7’s clinical record was initiated on 11/18/25.  The clinical record showed the SOC was 7/27/24.  The patient was certified for hospice services during the certification periods from 7/27/24 to 10/24/24, 10/25/24 to 1/22/25, 1/23/25 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, and 9/20/25 to 11/18/25.a.  Review of the physician’s order dated 10/27/25, showed an order for SN visits W1, 2W2, and 1W1, effective 10/26/25*However, the SN notes for Week 7 (10/26/25 to 11/1/25) showed two SN visits instead of three visits as per the physician’s order.b.  Review of the physician’s order dated 10/9/25, showed an order for MSW visits 1W3, effective 10/26/25*However, there was no documented evidence the MSW had visits for the weeks of 10/26/25 to 11/1/25, and 11/2/25 to 11/8/25.On 11/21/25 at 1343 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. The Administrator stated the missed visits were reported; however, there was no documented evidence the missed visits were offered for another day.  The Administrator and DPCS verified and acknowledged the findings.10. Review of Patient 13’s clinical record was initiated on 11/18/25. The clinical record showed the SOC was 1/12/23. The patient was certified for hospice services during the certification periods from 1/12/23 to 4/11/23, 4/12/23 to 7/10/23, 7/11/23 to 9/8/23, 9/9/23 to 11/7/23, 11/8/23 to 1/6/24, 1/7/24 to 3/6/24, 3/7/24 to 5/5/24, 5/6/24 to 7/4/24, 7/5/24 to 9/2/24, 9/3/24 to 11/1/24, 11/2/24 to 12/31/24, 1/1/25 to 3/1/25, 3/2/25 to 4/30/25, 5/1/25 to 6/29/25, 6/30/25 to 8/28/25, 8/29/25 to 10/27/25, and 10/28/25 to 12/26/25.Review of the physician’s order dated 8/14/25, showed an order may recertify the patient for the next hospice certification period (8/29/25 to 10/27/25). Documentation showed the calendar frequency for the SN was 1W8 effective 8/31/25.Review of the calendar of actual visits for the SN for Week 7 (10/5/25 to 10/11/25) showed the SN had two visits which were on 10/7/25 and 10/8/25.Review of the RN Visit Note Report dated 10/8/25, showed the visit type was SN Hospice PRN visit.  Documentation showed the patient was found on the floor next to the bed on the right side and an unwitnessed fall.  Documentation showed on inspection a small bump on the right side of the forehead.  Documentation showed the physician was notified and a new order was received for a floor mat.*However, review of the physician’s order dated 10/8/25, failed to show an order for the PRN visit.On 11/21/25 at 1020 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. They both verified and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the RN provided timely supervision to the LVNs to assess the quality of care and services provided for one of 19 sampled patients (Patient 7).  This failure had the potential of not providing the appropriate, consistent, and quality care to the patient.Findings: --- Review of Patient 7’s clinical record was initiated on 11/18/25.  The clinical record showed the SOC was 7/27/24.  The patient was certified for hospice services during the certification periods from 7/27/24 to 10/24/24, 10/25/24 to 1/22/25, 1/23/25 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, and 9/20/25 to 11/18/25. Review of the SN visit notes dated 10/3 and 11/6/25, showed the LVN conducted the visits; however, there was no documented evidence to show the RN had conducted the supervisory visit. On 11/21/25 at 1343 hours, an interview and concurrent clinical record review were conducted with the Administrator and DPCS.  The Administrator and DPCS were informed and verified the finding.

Based on interview and record review, the hospice failed to implement the bereavement program as per the hospice’s P&P to address the needs of the bereaved family members for two of three sampled deceased patients (Patient 2 and 3).  This failure created the increased risk of not addressing the bereavement needs of the bereaved family members.Findings: --- The hospice’s P&P titled Bereavement Program Policy and Procedure reviewed 10/1/24, showed the hospice will define and implement a structured, compliant and compassionate Bereavement Program that provides emotional, psychosocial, spiritual, and educational support to the family and caregivers of hospice patients for at least 12 months following the patient’s death.  Bereavement procedure includes the Post-Death Bereavement Risk Assessment completed within agency defined timeframe (commonly one to four weeks after death), using a standardized tool.  The Bereavement Plan of Care will be developed for each bereaved individual that includes: risk level, identified needs and problems, goals, planned interventions and contact schedule. The Bereavement Intervention includes condolence letters, phone calls, and home visits among others. xx. Review of Patient 3’s closed clinical record was initiated on 11/13/25.  The clinical record showed the SOC was 1/25/24.  The patient was certified for hospice during the certification periods from 1/25/24 to 4/23/24, 4/24/24 to 7/22/24, 6/14/24 to 8/12/24, 8/13/24 to 10/11/24, 10/12/24 to 12/10/24, 12/11/24 to 2/8/25, 2/9/25 to 4/9/25, and 4/10/25 to 6/2/25.  The patient expired on 6/2/25. There was no documented evidence of a post-death bereavement risk assessment was completed by the hospice after one to four weeks after the patient’s death as per the hospice’s P&P. There was no documented evidence a bereavement plan of care was completed by the Bereavement Coordinator after the patient’s death as per the hospice’s P&P. There was no documented evidence that condolence letters nor phone calls were provided to the bereaved family as per the hospice’s P&P. On 11/21/25 at 0833 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was informed and verified the findings. 2.  .  Review of Patient 2 ’s closed clinical record was initiated on 11/12/25. The clinical record showed the SOC was 2/5/25.  The patient was certified for hospice during the certification periods from 2/5/25 - 5/5/25 and 5/6/25 - 8/3/25.  Patient expired on 8/3/25.There was no documented evidence of a post-death bereavement risk assessment was completed by the hospice after one to four weeks after the patient’s death as per hospice’s P&P.There was no documented evidence that condolence letters nor phone calls were provided to the bereaved family as per hospice’s P&P.On 11/26/25 at 0855 hours, an interview and a concurrent clinical record review was conducted with the DPCS.  The DPCS was asked to show any documentation on Patient 2's bereavement process one to four weeks after the patient's death dated 8/3/25 and if there were any documentation of condolence letters or phone calls provided to the bereaved family.  The DPCS verified she was not able to find any documentation related on bereavement process for  Patient 2's family and caregivers.

Based on interview and record review, the hospice failed to ensure the HAs provided HA services in accordance with the POC for nine of 19 sampled patients (Patients 5, 6, 7, 9, 11, 14, 15, 17, and 18).  This failure had the potential for not providing the appropriate, consistent, and quality care to the patients. Findings: --- Review of the clinical records for Patients 5, 6, 7, 9, 11, 14, 15, 17, and 18 showed the HA did not follow the POC.  For example:  1.  Review of Patient 15's clinical record was initiated on 11/20/25.  The clinical record showed the SOC was 9/9/24.  The patient was certified for hospice services during the certification periods from 9/9/24 to 12/7/24, 12/8/24 to 3/7/25, 3/8/25 to 5/6/25, 5/7/25 to 7/5/25, 7/6/25 to 9/3/25, 9/4/25 to 11/2/25, and 11/3/25 to 1/1/26.   The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/3/25, cited HA visits 1W1, 2W8 effective 9/4/25.  Review of the Aide Care Plan Report for the certification periods from 9/4/25 to 11/2/25 and 11/3/25 to 1/1/26, showed the HA to provide ADL services including to shampoo in bed one time a week. However, review of the HA visit notes dated 9/5, 9/9, 9/12, 9/16, 9/19, 9/23, 9/26, 9/30,10/3, 10/7, 10/10,10/14, 10/17, 10/21, 10/24, 10/28, 10/31, 11/7, 11/11, 11/14 and 11/18/25, showed the HA provided shampoo in bed every visit instead of one time a week as per the POC.  On 11/25/25 at 1418 hours, an interview with concurrent clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.                                                                                                                                                 2.  Review of Patient 11's clinical record was initiated on 11/18/25.  The clinical record showed the SOC was 2/18/25.  The patient was certified for hospice services during the certification periods from 2/18/25 to 5/18/25, 5/19/25 to 8/16/25, 8/17/25 to 10/15/25, and 10/16/25 to 12/14/25.  The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 10/15/25, cited HA visits 1W1, 2W8  effective 10/16/25. Review of the Aide Care Plan Report for the certification periods from 8/17/25 to 10/15/25 and 10/16/25 to 12/14/25, showed the HA to provide ADL services including shampoo in bed one time a week. However, review of HA visit notes dated 8/19, 8/21, 8/26, 8/28, 9/2, 9/6/,9/9, 9/11, 9/16, 9/18, 9/23, 9/25, 9/30, 10/2, 10/7, 10/9, 10/16, 10/21, 10/23, 10/28, 10/30, 11/4, 11/6, 11/11, and 11/13/25, showed the HA provided shampoo in bed every visit instead of one time a week as per the POC. On 11/26/25 at 1030 hours, an interview with concurrent clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.                                                                                                                                                 3. Review of Patient 17's clinical record was initiated on 11/20/25.  The clinical record showed the SOC was 3/5/25.  The patient was certified for hospice services during the certification periods from 3/5/25 to 6/2/25, 6/3/25 to 8/31/25, 9/1/25 to 10/30/25, and 10/31/25 to 12/29/25.  The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 8/20/25, cited HA visits 3W9 effective 9/1/25.  The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 10/29/25, cited HA visits 2W8, 1W1 effective 11/2/25. Review of the Aide Care Plan Report for the certification periods from 9/1/25 to 10/30/25 and 10/31/25 to 12/29/25, showed the HA to  ADL services including to shampoo in bed one time a week. However, review of the HA visit notes dated 9/1, 9/3, 9/4, 9/8, 9/10, 9/11, 9/15, 9/17, 9/18, 9/22, 9/24, 9/25, 9/29,0/1,10/2,10/6, 10/8,10/9, 10/13,10/15, 10/16, 10/20, 10/22, 10/23, 10/27, 10/29, 10/30, 11/3, 11/6, 11/13, 11/17, and 11/19/25 showed the HA provided shampoo in bed every visit instead of one time a week as per the POC. On 11/25/25 at 1437 hours, an interview with concurrent clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the RN provided timely supervision to the HAs to assess the quality of care and services provided to nine of 19 sampled patients (Patients 5, 6, 7, 9, 11, 14, 15, 17, and 18).  This failure had the potential of not providing the appropriate, consistent, and quality care to the patients.Findings: --- xx.  Review of Patient 7’s clinical record was initiated on 11/18/25.  The clinical record showed the SOC was 7/27/24.  The patient was certified for hospice during the certification periods from 7/27/24 to 10/24/24, 10/25/24 to 1/22/25, 1/23/25 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, and 9/20/25 to 11/18/25. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/17/25, showed frequency of the HHA effective 9/21/25 was 2W8 and 1W1. Review of the HA notes showed HA 1 conducted the visits on 9/30, 10/2, 10/7, 10/9, 10/16, 10/21, 10/23, 10/28, and 10/30/25.  However, there was no documented evidence the RN conducted HA supervision every 14 days. On 11/21/25 at 1343 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS.  The Administrator and DPCS were informed and verified the finding. Review of the clinical records for Patients  5, 6, 7, 9, 11, 15 and 17  showed  the HA failed to follow the written care plan as ordered. For example: The hospice's P&P titled Employee Supervision reviewed 12/6/24 showed the purpose was to establish employee supervision practices in accordance with the applicable federal and state laws and regulations.  The policy showed supervision will be performed within the time frame defined by the policy.  The procedure includes a registered nurse (RN) must make an on-site visit to the patients home no less frequently than every14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the Hospice Interdisciplinary Group/Team (DG/IDT) meet the patients needs.  The hospice aide does not have to be present during the visit. 1.  Review of Patient 15's clinical record was initiated on 11/20/25.  The clinical record showed the SOC was 9/9/24.  The patient was certified for hospice services during the certification periods from 9/9/24 to 12/7/24, 12/8/24 to 3/7/25, 3/8/25 to 5/6/25, 5/7/25 to 7/5/25, 7/6/25 to 9/3/25, 9/4/25 to 11/2/25 and 11/3/25 to 1/1/26. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/3/25, cited HHA visit 1WK1, 2WK8 effective 9/4/25.Review of the clinical record during the certification period 9/4/25 to 11/2/25, showed HA 1 conducted the visits on 9/5, 9/9, 9/12, 9/16, 9/19, 9/23, 9/26, 9/30,10/3, 10/7, 10/10,10/14, 10/17, 10/21, 10/24, 10/28, 10/31/25.  Further review of the clinical records for the certification period 9/4/25 to 11/2/25, showed the RN had performed HA supervisory visit on 9/10, 10/5 and 10/15/25.  However, the RN supervisory visit was not conducted every 14 days as per P&P.On 11/25/25 at 1524 hours, an interview and concurrent clinical record review was conducted with the Administrator.  The Administrator was asked as to the frequency of HA supervisory visit.  The Administrator replied every 14 days.   The Administrator reviewed the clinical records and acknowledged the findings.     2. Review of Patient 11's clinical record was initiated on 11/18/25.  The clinical record showed the SOC was 2/18/25.  The patient was certified for hospice services during the certification periods from 2/18/25 to 5/18/25, 5/19/25 to 8/16/25, 8/17/25 to 10/15/25 and 10/16/25 to 12/14/25. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 10/15/25 cited HHA visit 1W1, 2W8  effective 10/16/25.Review of the clinical record during the certification period from 10/16/25 to 12/14/25 showed HA 4 conducted the visits on 10/16, 10/21, 10/23, 10/28, 10/30, 11/4, 11/6, 11/11 and 11/13/25.Further review of the clinical records for the certification period 10/16/25 to 12/14/25, showed the RN had performed HA supervisory visit on 11/6 and 11/14/25.  However, the RN supervisory visit was not conducted every 14 days as per P&P.On 11/26/25 at 1030 hours, an interview with concurrent clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.  #. Review of Patient 17's clinical record was initiated on 11/20/25.  The clinical record showed the SOC was 3/5/25.  The patient was certified for hospice services during the certification periods from 3/5/25 to 6/2/25, 6/3/25 to 8/31/25, 9/1/25 to 10/30/25 and 10/31/25 to 12/29/25. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 8/20/25 cited HHA visit 3W9 effective 9/1/25. In addition, review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 10/29/25 cited HHA visit 2W8, 1W1 effective 11/2/25.Review of the Aide hospice visit notes dated 9/1, 9/3, 9/4, 9/8, 9/10, 9/11, 9/15, 9/17, 9/18, 9/22, 9/24, 9/25, 9/29,0/1,10/2,10/6, 10/8,10/9, 10/13,10/15, 10/16, 10/20, 10/22, 10/23, 10/27, 10/29, 10/30, 11/3, 11/6, 11/13, 11/17 and 11/19/25. Review of the clinical record for the certification period 9/1/25 to 10/30/25 and 10/31/25 to 12/29/25 showed an RN had performed supervisory visits on 9/3, 9/15 and 11/10/25.  However, the RN supervisory visit was not conducted every 14 days as per P&P. On 11/25/25 at 1437 hours, an interview with concurrent clinical record review was conducted with the Administrator.  The Administrator was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the volunteers provided day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5% of the total patient care hours of all paid hospice employees and contract staff.  This failure created the risk of not addressing the patients' needs.Findings: --- Review of the hospice’s volunteer program was conducted on 11/20/25.  The hospice’s documents showed no documented evidence the volunteers provided day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5% of the total patient care hours of all paid hospice employees and contract staff for the years of 2024 and 2025. On 11/20/25 at 1506 hours, an interview and concurrent hospice document review was conducted with the Volunteer Coordinator.  The Volunteer Coordinator stated the hospice did not have volunteers since January 2024.   On 11/21/25 at 1600 hours, the Administrator and DPCS were informed and verified the finding.

Based on interview and record review, the hospice Administrator failed to be responsible for the day-to-day operations of the organization and maintain the administrative responsibility related to completion of tuberculosis screening for one of 10 employee files reviewed (Chaplain 2); and timely submission of clinical records.  This failure had the potential for spread of infection and not maintaining the complete medical records.Findings: --- Review of the hospice's P&P titled Timelines reviewed 9/1/24 showed, the hospice will ensure timely provision of care to meet patient's needs incompliance  with federal and state law requirements.   The hospice will establish staff responsibilities for acceptable timeframes for completion and submission of medical record information including, but not limited to : visit notes and assessments, physician orders, certifications and recertifications, transfer and discharges. XX.  Review of Patient 18 was initiated on 11/12/25.  The clinical record showed the SOC was 2/24/25.  The patient was certified for hospice services during certification periods 2/24/25 - 5/24/25, 5/25/25 to 8/22/25, 8/23/25 to 10/21/25 and 10/22/25 to 12/20/25.  Review of the physician's order dated 10/7/25, showed an order for SN effective 10/26/25 1w8.The agency's electronic system showed SN visit was conducted on 11/18/25 for week 4, 11/16/25 to 11/22/25.  However, there was no documentation of SN visit. On 11/26/25 at 0859 hours, an interview and concurrent document review was conducted with the DPCS.  The DPCS was asked if she could provide SN visit documentation dated 11/18/25.  The DPCS stated there was SN visit and verified the licensed nurse was not able to submit the SN visit documentation in a timely manner within 24- 48 hours.  The DPCS further acknowledged SN visits documentation should be submitted within 24-48 hours. Review of the hospice’s P&P titled Job Description/Performance Evaluation reviewed 10/1/24 showed the Administrators' primary function is to assume overall responsibility and authority for the administrative and leadership functions, supervision of the organizational plan, and responsibility for ongoing communication with the Governing Body and the interdisciplinary Group/Team (IDG/IDT), as well as the hospice staff.   The essential functions include to organize and directs the hospice's ongoing functions and ensures the hospice, including any multiple location(s), are in compliance with all applicable federal, state, and local laws and regulatory agencies related to health and safety of patients and ensures that the organization employs or contracts with qualified personnel. According to Standards of Quality Hospice Care 2005 Section 6.3 (a) (1) (2):-All persons providing physician, nursing or home health aide services shall have a health examination by a physician, nurse practitioner or physician’s assistant six months prior to employment or within 14 days of the date of employment.  The initial health examination shall include a tuberculosis screening. Review of the employee file was initiated on 11/21/25 with the Volunteer Coordinator/HR/Intake Manager.Review of the Chaplain 2 personnel file showed the hiring date of 6/14/23.  The file showed the physical examination and tuberculosis screening was completed on 10/27/22.   However, the TB testing was conducted more than six months prior to employment.On 11/21/25 at 1344 hours an interview and concurrent document review was conducted with the Volunteer Coordinator/HR/Intake Manager.  The Volunteer Coordinator/HR/Intake Manager was informed and acknowledged the finding.On 11/25/25 at 1247 hours, an interview and concurrent document review was conducted with the Administrator.  The Administrator was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the clinical records were complete and accurate for six of 19 sampled patients (Patients 3, 4, 7, 10, 14, and 16).  This failure had the potential risk of substandard care provided to the patients as their clinical information were not accurate and complete. --- Review of the hospice’s P&P titled Timelines last reviewed 9/1/24, showed the hospice will ensure timely provision of care to meet patient’s needs in compliance with all federal and state laws and regulations.  The hospice will establish staff responsibilities for acceptable timeframes for completion and submission of clinical record information including visit notes, assessments, physician orders, certifications and recertification, transfers and discharges.  Physician signatures are obtained on any updated IDG/IDT POC. #.  Review of Patient 3’s closed clinical record was initiated on 11/13/25.  The clinical record showed the SOC was 1/25/24.  The patient was certified for hospice during the certification periods from 1/25/24 to 4/23/24, 4/24/24 to 7/22/24, 6/14/24 to 8/12/24, 8/13/24 to 10/11/24, 10/12/24 to 12/10/24, 12/11/24 to 2/8/25, 2/9/25 to 4/9/25, and 4/10/25 to 6/2/25.  The patient expired on 6/2/25.a.  The MD Ordered and Approved Medications dated 3/26/25, included the following medications:-acetaminophen (analgesic) 500 mg tablet two times daily for chronic pain.-acetaminophen 500 mg tablet every four hours as needed for moderate pain.However, the RN Visit Note Report dated 4/19/25, showed the patient did not have pain and was not currently on pain management which was inconsistent with the physician's order. b.  The MD Ordered and Approved Medications dated 3/26/25, showed to administer oxygen for inhalation at 2 to 4 liters per minute as needed for shortness of breath.However, the RN Visit Note Report dated 4/26/25, showed there was no equipment available.  Also, on the section if oxygen safely stored, the SN documented not applicable which were inconsistent with the physician's order. c.  Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 4/9/25, showed the physician electronically signed on 8/1/25, which was more than 30 days of the updated IDG/IDT POC. On 11/21/25 at 0833 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. The DPCS confirmed that physician signatures should be obtained within 30 days.  The Administrator and DPCS were informed and verified the finding. xx.  Review of Patient 4’s closed clinical record was initiated on 11/14/25.  The clinical record showed the SOC was 12/23/24. The patient was certified for hospice services during the certification period 12/23/24 to 3/22/25.  The patient was discharged from hospice on 2/4/25. a.  Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 1/29/25 and 2/12/25, showed the physician electronically signed on 8/1/25, which was more than 30 days of the updated IDG/IDT POC. On 11/21/25 at 1141 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS.  The DPCS confirmed that physician signature should be obtained within 30 days.  The Administrator and DPCS were informed and verified and the finding. xx.  Review of Patient 7’s clinical record was initiated on 11/18/25.  The clinical record showed the SOC was 7/27/24.  The patient was certified for hospice during the certification periods from 7/27/24 to 10/24/24, 10/25/24 to 1/22/25, 1/23/25 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, and 9/20/25 to 11/18/25. a.  Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/17/25 and 10/1/25, showed the physician electronically signed on 11/12/25, which was more than 30 days of the updated IDG/IDT POC. b.  Review of the calendar showed an actual SN visit on 11/10/25 and 11/13/25.  However, there was no visit note completed. c.  Review of the calendar showed an actual HA visit on 11/13/25.  However, there was no visit note completed. On 11/21/25 at 1343 hours, an interview and concurrent clinical record review were conducted with the Administrator and DPCS.  The DPCS confirmed that physician signatures should be obtained within 30 days from the date of the clinical record.  Furthermore, visit notes should be completed with 24 hours of actual visit.  The Administrator and DPCS were informed and verified the findings.    xx.  Review of Patient 14’s clinical record was initiated on 11/19/25.  The clinical record showed the SOC was 8/1/24.  The patient was certified for hospice during the certification periods from 8/1/24 to 10/29/24, 10/30/24 to 12/28/24, 12/29/24 to 2/26/25, 2/27/25 to 4/27/25, 4/28/25 to 6/26/25, 6/27/25 to 8/25/25, 8/26/25 to 10/24/25, and 10/25/25 to 12/23/25. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/8/25 and 9/22/25, showed the physician  electronically signed on 11/5/25, which was not within the 30 days of any updated IDG/IDT POC. On 11/21/25 at 1425 hours, an interview and concurrent clinical record review were conducted with the Administrator and DPCS.  The DPCS confirmed that physician signature should be obtained within 30 days. The Administrator and DPCS were informed and verified the finding.   XX.  Review of Patient 10's physical copy of Nursing Visit Note dated 10/29/25 showed, goal of visit was for assessment and education.  However, Patient 10's Nursing Visit Note showed blank documentation on the following sections: a.  The Emergency Preparedness Assessment section that showed assessment for mobility status: if patient is ambulatory, non ambulatory, wheelchair, chairbound or bedbound; assessment on special needs: if patient is electricity dependent, communication challenges, language barriers, intellectual disabilities, special dietary needs, essential medications, etc. b. The Coordination of Care/Professional Management Education that showed assessment on review with patient/ caregiver/ physician; if coordinated care with IDG, physician, orders received, plan of care updated. On 11/24/25 at 1442 hours, an interview and concurrent clinical record review were conducted with the DPCS.  The DPCS was informed on Patient 2's Nursing Visit Note dated 10/29/25, showed no assessment on Emergency Preparedness and Coordination of Care/Professional Management Education and was asked if it should have been completed.  The DPCS verified it should have been completed.  XX.  Review of Patient 16's clinical record was initiated on 11/12/25. The clinical record showed the SOC was 9/3/25. The patient was certified for hospice services during certification period 9/3/25 to 12/1/25. Review of the Patient 16's RN visit notes showed the following:-dated 9/19/25 , 10/7/25, and 10/21/25 showed no documentation on MAC measurement.-dated 9/3/25 showed Patient 16's genitourinary assessment indicated Patient 16 was with Nephrostomy tube.  Patient 16's narrative documentation showed Patient 16 was with Right arm PICC line,   nephrostomy tube x 2, colostomy and with IV antibiotics x 2 for pseudomonas and MRSA. -dated 9/5/25, Patient 16's  assessment on type of ostomy showed Patient 16 was with colostomy. Patient 16's narrative documentation showed Patient 16 was with right nephrostomy.-dated 9/9/25, Patient 16's assessment on type of ostomy showed colostomy. Patient16's narrative documentation showed Patient 16 was with PICC line dressing to right arm changed and on antibiotic therapy. -dated 9/16/25, Patient 16's assessment on type of ostomy showed Patient 16 was with colostomy.  Patient 16's narrative documentation showed Patient 16 was with PICC line dressing changed, on IV antibiotic therapy.-dated 9/19/25, Patient 16's assessment on type of ostomy showed Patient was with colostomy.  Patient 16's narrative documentation showed Patient 16 was with PICC line removed per patient request , IV antibiotics completed.-dated 9/30/25, Patient 16's  genitourinary assessment showed Patient 16 was with nephrostomy tube and type of ostomy showed colostomy. Patient 16's narrative documentation showed Patient 16 was on antibiotic prophylaxis.-dated 10/7/25, Patient 16's narrative documentation showed Patient 16 was with colostomy and with nephrostomy tubing.-dated 10/14/25, 10/21/25, 10/28/25, and 11/11/25, Patient 16's genitourinary assessment showed Patient 16 was with nephrostomy tube and type of ostomy showed colostomy.*However, there was no documentation showing interventions provided or goals met on Patient 16's colostomy, nephrostomy, antibiotic therapy and PICC line care and there was no specific, detailed assessment documentation on Patient 16's PICC line site and care. On 11/24/25 at 1304 hours, an interview and concurrent clinical record review was conducted with DPCS.  The DPCS was asked what was the agency protocol for any missed visits.  The DPCS stated the patient should be offered another visit.  The DPCS was further asked for any documentation of any SN visit for the week of 11/2/25 to 11/8/25. The DPCS verified it was missed and acknowledged she could not find any documentation to show an attempted visit was arranged for Patient 16.  The DCPS was also asked how frequent licensed nurses should conduct MAC measurements. The DCPS stated the MAC measurement should be measured every 14 days.  The DCPS was informed on Patient 16's missed MAC measurements and DCPS verified the MAC measurements should have been done.  Additionally, the DPCS asked if there was any specific documentation she could show that interventions provided or were the goals met regarding Patient 16's colostomy, nephrostomy, antibiotic therapy, PICC line care as well as if there were any documentation of detailed PICC line assessment conducted from the above-mentioned dates .  The DPCS verified she could not find any specific documentation regarding interventions were provided or if goals were met regarding Patient 16's colostomy, nephrostomy, antibiotic therapy, PICC line care and further verified she could not find any specific, detailed documentation of PICC line assessment from above dates mentioned.   Review of the hospice’s P&P titled Timelines last reviewed 9/1/24, showed the hospice will ensure timely provision of care to meet patient’s needs in compliance with all federal and state laws and regulations.  The hospice will establish staff responsibilities for acceptable timeframes for completion and submission of clinical record information including visit notes, assessments, physician orders, certifications and recertification, transfers and discharges.  Physician signatures are obtained on any updated IDG/IDT POC. 1.  Review of Patient 3’s closed clinical record was initiated on 11/13/25.  The clinical record showed the SOC was 1/25/24.  The patient was certified for hospice during the certification periods from 1/25/24 to 4/23/24, 4/24/24 to 7/22/24, 6/14/24 to 8/12/24, 8/13/24 to 10/11/24, 10/12/24 to 12/10/24, 12/11/24 to 2/8/25, 2/9/25 to 4/9/25, and 4/10/25 to 6/2/25.  The patient expired on 6/2/25.a.  The MD Ordered and Approved Medications dated 3/26/25, included the following medications:-acetaminophen (analgesic) 500 mg tablet two times daily for chronic pain.-acetaminophen 500 mg tablet every four hours as needed for moderate pain.However, the RN Visit Note Report dated 4/19/25, showed the patient did not have pain and was not currently on pain management which was inconsistent with the physician's order. b.  The MD Ordered and Approved Medications dated 3/26/25, showed to administer oxygen for inhalation at 2 to 4 liters per minute as needed for shortness of breath.However, the RN Visit Note Report dated 4/26/25, showed there was no equipment available.  Also, on the section if oxygen was safely stored, the SN documented not applicable which was inconsistent with the physician's order. c.  Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 4/9/25, showed the physician electronically signed on 8/1/25, which was more than 30 days of the updated IDG/IDT POC. On 11/21/25 at 0833 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. The DPCS confirmed that physician signatures should be obtained within 30 days.  The Administrator and DPCS were informed and verified the finding. 2.  Review of Patient 4’s closed clinical record was initiated on 11/14/25.  The clinical record showed the SOC was 12/23/24. The patient was certified for hospice services during the certification period 12/23/24 to 3/22/25.  The patient was discharged from hospice on 2/4/25. a.  Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 1/29/25 and 2/12/25, showed the physician electronically signed on 8/1/25, which was more than 30 days of the updated IDG/IDT POC. On 11/21/25 at 1141 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS.  The DPCS confirmed that physician signature should be obtained within 30 days.  The Administrator and DPCS were informed and verified and the finding. 3.  Review of Patient 7’s clinical record was initiated on 11/18/25.  The clinical record showed the SOC was 7/27/24.  The patient was certified for hospice during the certification periods from 7/27/24 to 10/24/24, 10/25/24 to 1/22/25, 1/23/25 to 3/23/25, 3/24/25 to 5/22/25, 5/23/25 to 7/21/25, 7/22/25 to 9/19/25, and 9/20/25 to 11/18/25. a.  Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/17/25 and 10/1/25, showed the physician electronically signed on 11/12/25, which was more than 30 days of the updated IDG/IDT POC. b.  Review of the calendar showed an actual SN visit on 11/10/25 and 11/13/25.  However, there was no visit note completed. c.  Review of the calendar showed an actual HA visit on 11/13/25.  However, there was no visit note completed. On 11/21/25 at 1343 hours, an interview and concurrent clinical record review were conducted with the Administrator and DPCS.  The DPCS confirmed that physician signatures should be obtained within 30 days from the date of the clinical record.  Furthermore, visit notes should be completed with 24 hours of actual visit.  The Administrator and DPCS were informed and verified the findings.    4.  Review of Patient 14’s clinical record was initiated on 11/19/25.  The clinical record showed the SOC was 8/1/24.  The patient was certified for hospice during the certification periods from 8/1/24 to 10/29/24, 10/30/24 to 12/28/24, 12/29/24 to 2/26/25, 2/27/25 to 4/27/25, 4/28/25 to 6/26/25, 6/27/25 to 8/25/25, 8/26/25 to 10/24/25, and 10/25/25 to 12/23/25. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/8/25 and 9/22/25, showed the physician  electronically signed on 11/5/25, which was not within the 30 days of any updated IDG/IDT POC. On 11/21/25 at 1425 hours, an interview and concurrent clinical record review were conducted with the Administrator and DPCS.  The DPCS confirmed that physician signature should be obtained within 30 days. The Administrator and DPCS were informed and verified the finding.   5.  Review of Patient 10's Nursing Visit Note dated 10/29/25, showed the goal of visit was for assessment and education.  However, Patient 10's Nursing Visit Note showed the following sections were left blank: The Emergency Preparedness Assessment section which included the assessment for mobility status: if patient is ambulatory, non ambulatory, wheelchair, chairbound or bedbound; assessment on special needs: if patient is electricity dependent, communication challenges, language barriers, intellectual disabilities, special dietary needs, essential medications, etc. The Coordination of Care/Professional Management Education which included the review with patient/ caregiver/ physician; if coordinated care with IDG, physician, orders received, plan of care updated. On 11/24/25 at 1442 hours, an interview and concurrent clinical record review were conducted with the DPCS.  The DPCS was informed on the findings and was asked if it should have been completed.  The DPCS verified it should have been completed.  6.  Review of Patient 16's clinical record was initiated on 11/12/25.  The clinical record showed the SOC was 9/3/25. The patient was certified for hospice services during certification period 9/3/25 to 12/1/25. Review of the Patient 16's RN visit notes showed the following:-Dated 9/19, 10/7, and 10/21/25, failed to show documented evidence the patient's MAC was measured.-Dated 9/3/25, showed Patient 16 had nephrostomy tube, PICC line on the right arm, and colostomy.  Patient 16 was on IV antibiotics for pseudomonas and MRSA.-Dated 9/5/25, Patient 16 had colostomy and right nephrostomy.-Dated 9/9 and 9/16/25, Patient 16 had colostomy, PICC line dressing to the right arm was changed, and on antibiotic therapy.-Dated 9/19/25, Patient 16 had colostomy, PICC line was removed as per the patient's request, IV antibiotic was completed.-Dated 9/30/25, Patient 16 had nephrostomy tube and colostomy; and on antibiotic prophylaxis.-Dated 10/7/25, Patient 16's narrative documentation showed Patient 16 was with colostomy and with nephrostomy tubing.-dated 10/14/25, 10/21/25, 10/28/25, and 11/11/25, Patient 16's genitourinary assessment showed Patient 16 was with nephrostomy tube and type of ostomy showed colostomy.*However, there was no documentation showing interventions provided or goals met on Patient 16's colostomy, nephrostomy, antibiotic therapy and PICC line care and there was no specific, detailed assessment documentation on Patient 16's PICC line site and care. On 11/24/25 at 1304 hours, an interview and concurrent clinical record review was conducted with DPCS.  The DPCS was asked what was the agency protocol for any missed visits.  The DPCS stated the patient should be offered another visit.  The DPCS was further asked for any documentation of any SN visit for the week of 11/2/25 to 11/8/25. The DPCS verified it was missed and acknowledged she could not find any documentation to show an attempted visit was arranged for Patient 16.  The DCPS was also asked how frequent licensed nurses should conduct MAC measurements. The DCPS stated the MAC measurement should be measured every 14 days.  The DCPS was informed on Patient 16's missed MAC measurements and DCPS verified the MAC measurements should have been done.  Additionally, the DPCS asked if there was any specific documentation she could show that interventions provided or were the goals met regarding Patient 16's colostomy, nephrostomy, antibiotic therapy, PICC line care as well as if there were any documentation of detailed PICC line assessment conducted from the above-mentioned dates .  The DPCS verified she could not find any specific documentation regarding interventions were provided or if goals were met regarding Patient 16's colostomy, nephrostomy, antibiotic therapy, PICC line care and further verified she could not find any specific, detailed documentation of PICC line assessment from above dates mentioned.

Based on interview and record review, the hospice failed to authenticate the entries made into the clinical records of four of 19 sampled patients (Patients 3, 4, and 13).   This failure had the potential to not have verified patient information.Findings: --- Review of the hospice’s P&P titled Authorization and Authentication of Medical Record Entries last reviewed 9/1/24, showed all medical record entries whether paper, electronic or combination format will be made by appropriate staff and authenticated as true and accurate by the author of the entry.  Each medical record entry will be dated and signed with the complete name and title and/or credential of the person making the entry. 1. Review of Patient 3’s closed clinical record was initiated on 11/13/25.  The clinical record showed the SOC was 1/25/24.  The patient was certified for hospice services during the certification periods from 1/25/24 to 4/23/24, 4/24/24 to 7/22/24, 6/14/24 to 8/12/24, 8/13/24 to 10/11/24, 10/12/24 to 12/10/24, 12/11/24 to 2/8/25, 2/9/25 to 4/9/25 and 4/10/25 to 6/2/25.  The patient expired on 6/2/25. a.  Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 4/9/25, failed to show the electronic signature of the hospice physician. b.  Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 4/23 and 5/21/25, failed to show the date when the physician signed the report. On 11/21/25 at 0833 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS.  They were informed and verified the findings. 2. Review of Patient 4’s closed clinical record was initiated on 11/14/25.  The clinical record showed the SOC was 12/23/24.  The patient was certified for hospice services during the certification period 12/23/24 to 3/22/25.  The patient was discharged from the hospice on 2/4/25. a.  Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 12/30/24, failed to show the electronic signature of the hospice physician. b.  Review of the Hospice IDG Comprehensive Assessment and Plan of care Update Report dated 1/13/25, failed to show the date when the physician signed the report. On 11/21/25 at 1114 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS.  They were informed and verified the findings. 3. Review of Patient 13’s clinical record was initiated on 11/18/25.  The clinical record showed the SOC was 1/12/23.  The patient was certified for hospice services during the certification periods from 1/12/23 to 4/11/23, 4/12/23 to 7/10/23, 7/11/23 to 9/8/23, 9/9/23 to 11/7/23, 11/8/23 to 1/6/24, 1/7/24 to 3/6/24, 3/7/24 to 5/5/24, 5/6/24 to 7/4/24, 7/5/24 to 9/2/24, 9/3/24 to 11/1/24, 11/2/24 to 12/31/24, 1/1/25 to 3/1/25, 3/2/25 to 4/30/25, 5/1/25 to 6/29/25, 6/30/25 to 8/28/25, 8/29/25 to 10/27/25 and 10/28/25 to 12/26/25. a.  Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 10/13/25, failed to show the date when the physician signed the report. b.  Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 11/5/25, failed to show electronic signature of the hospice physician and pastor/counselor. On 11/21/25 at 1020 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS.  They were informed and verified the findings.

Based on interview and record review, the hospice failed to ensure the emergency preparedness P&P addressed the procedures to follow up with the on-duty staff and patients to determine if the interruption of services occurred; and inform the State and local officials of any on-duty staff or patients that they were unable to contact, creating the risk of not providing the care and services needed by the patients. --- Findings: Review of the hospice's emergency preparedness plan and P&P was initiated on 11/16/22. The hospice's emergency preparedness P&P failed to include the procedures to follow up with the on-duty staff and patients to determine the services that were needed in the event that there was an interruption of services during or due to an emergency and inform the State and local officials of any on-duty staff or patients that they were unable to contact. On 11/18/22 at 1342 hours, an interview with concurrent record review was conducted with the DPCS. The DPCS was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the emergency preparedness P&P addressed the procedures to inform State and local emergency preparedness officials about the patients in need of evacuation from their residences due to an emergency situation based on the patient's psychiatric condition. This failure created the increased risk of not evacuating the patients timely. --- Findings: Review of the hospice's emergency preparedness plan and P&P was initiated on 11/16/22. The emergency preparedness P&P failed to include the procedures to inform State and local emergency preparedness officials about the patients in need of evacuation from their residences due to an emergency situation based on the patient's psychiatric condition. On 11/18/22 at 1342 hours an interview with concurrent document review was conducted with the DPCS. The DPCS was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to develop the emergency preparedness P&P addressing a system of medical documentation that protected confidentiality of the patient information. This created the risk of not protecting the patient's confidential information during an emergency. --- Findings: Review of the hospice's emergency preparedness P&P was initiated on 11/16/22. However, the P&P did not address a system of medical documentation that protected confidentiality of the patient information. On 11/18/22 at 1342 hours, an interview with concurrent document review was conducted with the DPCS. The DPCS was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to develop the emergency preparedness P&P addressing the development of arrangements with other facilities and other providers to receive the patients in the event of limitations or cessation of operations to maintain the continuity of services to the facility patients. This posed the risk of not addressing the patients' needs during an emergency. --- Findings: Review of the hospice's emergency preparedness P&P was initiated on 11/16/22. However, there was no P&P addressing the development of an arrangement with other facilities and other providers to receive the patients in the event of limitations or cessation of operations to maintain the continuity of services to the facility patients. On 11/18/22 at 1342 hours, an interview with concurrent document review was conducted with the DPCS. The DPCS was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to develop the communication plan to include the contact information of other hospices, creating the risk of not able to contact or request for assistance during an emergency. --- Findings: Review of the hospice's emergency preparedness plan was initiated on 11/16/22. However, there was no documented evidence tje communication plan was developed to include the contact information of other hospices. On 11/18/22 at 1342 hours an interview with concurrent document review was conducted with the DPCS. The DPCS was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the emergency preparedness communication plan included the method for sharing the information and medical documentation for the agency's patients with other health providers to maintain the continuity of care, creating the increased risk of not providing appropriate, consistent, and quality care to the patients during an emergency. --- Findings: Review of the hospice's emergency preparedness plan was initiated on 11/16/22. However, the plan failed to include the method for sharing information and medical documentation for the agency's patients with other health providers to maintain the continuity of care. On 11/18/22 at 1342 hours an interview with concurrent document review was conducted with the DPCS. The DPCS was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the hospice RN completed the initial assessment within 48 hours after the election of hospice care for one of 17 sampled patients (Patient 12), creating the risk of not addressing the care needs for this patient timely --- Findings: Review of Patient 12's closed clinical record was initiated on 11/15/22. The patient's closed clinical record showed the SOC was 6/28/22. The patient was certified for hospice services during the certification period from 6/28/22 to 9/25/22. Review of the patients Election of Medicare Hospice Benefit, showed the patient signed the document on 6/21/22. Further review of the clinical record showed the RN conducted the initial start of care visit on 6/28/22, which was more than 48 hours after the election of hospice care. On 11/18/22 at 1205 hours, a concurrent clinical record review and interview was conducted with RN 1. She was informed and acknowledged the finding.

Based on interview and clinical record review, the hospice failed to ensure the comprehensive assessments identified the imminence of deaths for one of 17 sampled patients (Patients 16), creating the risk of not appropriately addressing the patient's needs. --- Findings: Review of Patient 16's clinical record was initiated on 11/10/22. The clinical record showed the SOC was 11/5/18. The patient was certified for hospice services during the certification periods from 8/16/22 to 10/14/22 and 10/15/22 to 12/13/22. Further review of the clinical record showed the initial comprehensive assessment did not identify the imminence of death for this patient. On 11/18/22 at 1100 hours, a concurrent clinical record review and interview was conducted with RN 1. She was informed of the finding.

Based on interview and record review, the hospice failed to ensure the medication profiles were reviewed and updated to reflect the current medications and include specific indications and parameters for its use for four of 17 sampled patients (Patients 4, 15, 16 and 17). These failures created the risk for the patients not receiving the appropriate care and services necessary to improve the patients' health conditions. --- #. Review of Patient 4's clinical record was initiated on 11/16/22. The patient's clinical record showed the SOC was 6/21/22. The patient was certified for hospice services during the certification period from 9/19/22 to 11/17/22. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/27, 10/11, 10/25, and 11/8/22, showed the patients medications included hydrocodone 5 mg - acetaminophen 325 mg (opioid analgesic) one tablet PO Q six hours PRN for pain and morphine (opioid analgesic) 15 mg one tablet PO Q four hours PRN for pain/SOB. * However, there was no documented evidence of the instructions for which pain medication should be administered first. On 11/18/22 at 1400 hours, a concurrent clinical record review and interview was conducted with RN 1. She was informed and acknowledged the finding. #. Review of Patient 15's clinical record was initiated on 11/10/22. The clinical record showed the SOC was 2/25/22. The patient was certified for hospice services during the certification periods from 8/24/22 to 10/22/22 and 10/23/22 to 12/21/22. The patient resided in a SNF. A joint home visit with HA 2 to the patient's SNF was conducted on 11/10/22 at 0910 hours. Review of the SNF's MAR for November 2022 showed the patient's medications included the following: - melatonin (supplement) 10 mg PO Q HS - Pataday (allergy eye itch relief) solution 0.7% one drop in both eyes QD - Xanax (antianxiety) 0.25 mg one tablet PO Q HS - Restasis (indicated to increase tear production) Emulsion one drop in both eyes BID - Refresh tears (ocular lubricant) one drop in both eyes TID - acetaminophen (analgesic) 650 mg PO Q four hours PRN for mild pain However, the Medicine List for the certification period from 10/23/22 to 12/21/22, did not include melatonin, Pataday, and Restasis Emulsion. Documentation showed the patient was on Xanax 0.25 mg one tab PO BID, instead of q HS; acetaminophen 650 mg PO Q four hours, instead of 650 mg PO Q four hours PRN; and Refresh tears one drop in left eye TID, instead of both eyes. The hospice failed to update the patient's medication profile to reflect the patient's current medication. On 11/18/22 at 945 hours, a concurrent clinical record review and interview was conducted with RN 1. She was informed and acknowledged the finding. #. Review of Patient 16's clinical record was initiated on 11/10/22. The clinical record showed the SOC was 11/5/18. The patient was certified for hospice services during the certification periods from 8/16/22 to 10/14/22 and 10/15/22 to 12/13/22. A joint home visit with RN 2 to the patient's home was conducted on 11/10/22 at 1300 hours. The Medicine List for the certification period from 10/15/22 to 12/13/22, showed the patient was on Miralax (laxative) 17 gm PO BID, ketotifen (antihistamine) 0.025% ophthalmic one drop Q six hours, and lactulose (laxative) 20 gm/30 ml 30 ml Q afternoon. However, an interview was conducted with the patients family member. The family member stated Miralax, ketotifen, and lactulose was administered to the patient PRN and not routine. The hospice failed to update the patient's medication profile to reflect the patient's current medication. On 11/10/22 at 1030 hours, RN 2 was informed of the findings. On 11/18/22 at 1100 hours, a concurrent clinical record review and interview was conducted with RN 1. She was informed of the finding. Review of the hospice's P&P titled Medication Profile revised date April 2013, showed patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. The medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. 1. Review of Patient 17's clinical record was initiated on 11/14/22. The clinical record showed the SOC was 6/5/22. The patient was certified for hospice services during the certification period from 10/3/22 to 12/1/22.On 11/10/22 at 1100 hours, a joint home visit was conducted with LVN 1 to Patient 17's home. Review of the patient's medications with LVN 1 showed the patient was taking Synthroid (synthetic thyroid hormone) 100 mcg PO Q AM instead of Synthroid 112 mcg PO Q AM. The patient was also taking hydrocodone-acetaminophen 5/325 mg one tablet PO Q six hours PRN for moderate pain instead of hydrocodone-acetaminophen 5/325 mg one tablet PO Q four hours PRN for moderate pain. On 11/10/22 at 1210 hours, an interview and concurrent clinical record review was conducted with LVN 1. LVN 1 was informed and verified the finding.

Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POCs for four of 17 sampled patients (Patients 1, 7, 15, and 17), creating the risk of not providing appropriate, consistent, and quality care to these patients. --- #. Review of Patient 15's clinical record was initiated on 11/10/22. The clinical record showed the SOC was 2/25/22. The patient was certified for hospice services during the certification periods from 8/24/22 to 10/22/22 and 10/23/22 to 12/21/22. The patient resided in a SNF. The physicians order dated 10/8/22, showed Chaplain visit 1W1, 1Q5W5, and 2 PRN effective 10/23/22 Further review of the clinical record showed no Chaplain visit instead of one on Week 1 (10/23/22 to 10/29/22). On 11/18/22 at 945 hours, a concurrent clinical record review and interview was conducted with RN 1. She was informed and acknowledged the finding. 1. Review of Patient 1's clinical record was initiated on 11/9/22. The clinical record showed the SOC was 6/9/22. The patient was certified for hospice services during the certification period from 9/7/22 to 12/5/22. Review of the recertification orders dated 8/23/22, cited Chaplain visits 1W1, 1Q4W4, 1Q5W5, and two PRN visits for spiritual support and counseling effective 9/7/22. Review of the clinical record showed no documented evidence the Chaplain visited the patients home from 9/7/22 to 9/10/22. On 11/18/22 at 1151 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and verified the finding. 2a. Review of Patient 7's clinical record was initiated on 11/15/22. The clinical record showed the SOC was 7/8/21. The patient was certified for hospice services during the certification period from 11/5/22 to 1/3/23. Review of the recertification orders dated 10/21/22, cited MSW visits 1W1, 1Q5W5, and two PRN visits for emotional support, counseling, and assistance effective on 11/5/22. Review of the clinical record showed no documented evidence the MSW visited the patients home on 11/5/22. b. Review of the SN notes dated 10/20, 10/24, and 10/31/22, showed the SN applied Calmoseptine (moisture barrier ointment) to the patients rash on his sacral area. However, review of the physician orders and medication profile did not show the order for Calmoseptine. On 11/18/22 at 1059 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and verified the finding. 3. Review of Patient 17's clinical record was initiated on 11/14/22. The clinical record showed the SOC was 6/5/22. The patient was certified for hospice services during the certification period from 8/4/22 to 10/2/22. Review of the POC showed a care plan problem addressing the patients need for skilled teaching and monitoring the use of oxygen.Review of the SN Notes for the certification period showed the SN was documenting the patient's use of supplemental oxygen.For example, on 8/4/22, the SN documented the patient had an oxygen saturation of 96% on five liters of oxygen. However, review of the physician orders and medication profile did not show the order for oxygen administration. On 11/18/22 at 1042 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and verified the finding.

Based on interview and record review, the hospice failed to ensure the individualized care plans were developed for 12 of 17 sampled patients (Patients 1, 2, 4, 6, 9, 10, 11, 12, 13, 15, 16, and 17). This failure had posed the risk for inconsistent delivery of care which could result in the decline or lack of improvement of the patients' health conditions. --- 3. Review of Patient 17's clinical record was initiated on 11/14/22. The clinical record showed the SOC was 6/5/22. The patient was certified for hospice services during the certification periods from 8/4/22 to 10/2/22 and 10/3/22 to 12/1/22. Review of the recertification orders dated 7/20/22, cited HA visits 1W1 and 3W8 effective on 8/4/22. Review of the recertification orders dated 9/18/22, cited HA visits 3W8 and 2W1 effective on 10/3/22. The Aide Care Plan Report for both certification periods showed to perform vital signs assessments of the patients temperature and respirations. However, review of all of the HA notes for both certification periods showed documentation that the patient refused the temperature and respiration assessments. The HA documented that the RN was notified of the patients refusal. Review of the IDG Comprehensive Assessment and Plan of Care Update Report for both certification periods showed no documented evidence the IDG had discussed the patients refusal for the above HA task. In addition, there was no individualized care plan problem developed to address the patients refusal of vital signs assessments. On 11/18/22 at 1042 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and verified the finding. Cross reference L 554 example #6 4. Review of Patient 1's clinical record was initiated on 11/9/22. The clinical record showed the SOC was 6/9/22. The patient was certified for hospice services during the certification period from 9/7/22 to 12/5/22. Review of the SN Notes dated 9/16, 9/23, 10/21, and 10/28/22, showed documentation the patient had edema. However, review of the care plan showed no documented evidence the care plan problem for edema was developed. On 11/18/22 at 1151 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and verified the finding. 5. Review of Patient 6's clinical record was initiated on 11/16/22. The clinical record showed the SOC was 9/12/21. The patient was certified for hospice services during the certification periods from 8/8/22 to 10/6/22 and 10/7/22 to 12/5/22. Review of the recertification orders dated 7/24/22, cited HA visits 3W8 and 2W1 effective on 8/8/22. Review of the recertification orders dated 9/22/22, cited HA visits 1W1, 3W8, and 1W1 effective on 10/7/22. The Aide Care Plan Report for both certification periods showed to perform vital signs assessments of the patients temperature, pulse, and respirations. However, review of all of the HA notes for both certification periods showed documentation that the patient refused the temperature, pulse, and respiration assessments. The HA documented that the RN was notified of the patients refusal. Review of the IDG Comprehensive Assessment and Plan of Care Update Report for both certification periods showed no documented evidence the IDG had discussed the patients refusal for the above HA task. The IDG failed to supervise the care and services provided to the patient. In addition, there was no individualized care plan problem developed to address the patients refusal of vital signs assessments. On 11/18/22 at 1122 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and verified the finding. Cross reference L 554 example #7 1. Review of Patient 2's clinical record was initiated on 11/9/22. The patient's clinical record showed the SOC was 6/4/20. The patient was certified for hospice services during the certification period from 9/22/22 to 11/20/22. Review of the IDG Comprehensive Assessment and Plan of Care Update Report dated 10/9, 10/23, and 11/6/22, showed the patients medications included Remeron (antidepressant) 15 mg one tablet PO Q HS and Seroquel (antipsychotic) 50 mg one tablet BID. * However, review of the patient's plan of care showed no documented evidence the care plan problems were developed to address the use of Remeron and Seroquel. On 11/18/22 at 1145 hours, a concurrent clinical record review and interview was conducted with RN 1. She was informed and acknowledged the finding. 2. Review of Patient 4's clinical record was initiated on 11/16/22. The patient's clinical record showed the SOC was 6/21/22. The patient was certified for hospice services during the certification period from 9/19/22 to 11/17/22. Review of the IDG Comprehensive Assessment and Plan of Care Update Report dated 10/25/22 and 11/8/22, showed the patients medications included alprazolam (antianxiety) 0.25 mg one tablet PO TID and Lexapro (antidepressant) 5 mg one tablet PO QD. * However, review of the patient's plan of care showed no documented evidence the care plan problems were developed to address the use of alprazolam and Lexapro. On 11/18/22 at 1400 hours, a concurrent clinical record review and interview was conducted with RN 1. She was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the initial and revised POCs included the discipline visit frequencies and/or the indication for the PRN discipline visits for 10 of 17 sampled patients (Patients 2, 5, 7, 8, 9, 12, 13, 15, 16, and 17), creating the risk of not providing necessary services for these patients. --- Findings: Review of the clinical records for Patients 2, 5, 7, 8, 9, 12, 13, 15, 16, and 17, failed to include the discipline visit frequencies on the revised POCs. For example: 1. Review of Patient 17's clinical record was initiated on 11/14/22. The clinical record showed the SOC was 6/5/22. The patient was certified for hospice services during the certification period from 10/3/22 to 12/1/22. Review of the recertification orders dated 9/18/22, cited two PRN SN visits for symptom management, two PRN MSW visits for emotional support counseling and assistance, and two PRN chaplain visits for spiritual support and counseling. However, there was no specific frequency and how often the PRN visits were supposed to be conducted. On 11/18/22 at 1042 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and verified the finding. 2. Review of Patient 8's clinical record was initiated on 11/10/22. The clinical record showed the SOC was 3/16/22. The patient was certified for hospice services during the certification period from 9/12/22 to 11/10/22. Review of the recertification orders dated 8/28/22, cited MSW visits 3W1 and 3 PRN visits for emotional support and counseling. Review of the IDG Comprehensive Assessment and Plan of Care Update Report dated 9/28, 10/12, and 10/26/22, showed no documented evidence the IDG had discussed the MSW and HA visit frequencies. On 11/18/22 at 1137 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and verified the finding.

Based on interview and record review, the hospice failed to ensure the POCs included measurable outcomes for 10 of 17 sampled patients (Patients 1, 2, 3, 4, 5, 9, 11, 15, 16, and 17), creating the risk of not evaluating the POC and providing appropriate care and services to these patients. --- #. Review of Patient 2's clinical record was initiated on 11/9/22. The patient's clinical record showed the SOC was 6/4/20. The patient was certified for hospice services during the certification period from 9/22/22 to 11/20/22. The POC, for the certification period from 9/22/22 to 11/20/22, showed the patient's identified problems with the established goals and interventions. However, the POC failed to include the measurable outcomes for the patient's identified problems. For example, the expected outcome for need for skilled assessment and intervention of bowel impaction was for patient to have effective and timely bowel movements. * However, there was no measurable outcome as to what the patient's effective and timely bowel movements would be. On 11/18/22 at 1145 hours, a concurrent clinical record review and interview was conducted with RN 1. She was informed and acknowledged the finding. 2. Review of Patient 4's clinical record was initiated on 11/16/22. The patient's clinical record showed the SOC was 6/21/22. The patient was certified for hospice services during the certification period from 9/19/22 to 11/17/22. The POC, for the certification period from 9/19/22 to 11/17/22, showed the patient's identified problems with the established goals and interventions. However, the POC failed to include the measurable outcomes for the patient's identified problems. For example: the expected outcome for the need for observation and assessment of altered comfort was for increased pain/unmanaged pain will be promptly identified through pain assessment. However, there was no measurable outcome as to what the patients increase pain or unmanaged pain would be. On 11/18/22 at 1400 hours, a concurrent clinical record review and interview was conducted with RN 1. She was informed and acknowledged the finding. Review of the clinical records for Patients 1, 2, 3, 4, 5, 9, 11, 15, 16, and 17, showed the POCs did not include the measurable outcomes anticipated to evaluate the effectiveness of the plan of care to meet the patients' needs. For example: 1. Review of Patient 17's clinical record was initiated on 11/14/22. The clinical record showed the SOC was 6/5/22. The patient was certified for hospice services during the certification periods from 8/4/22 to 10/2/22 and 10/3/22 to 12/1/22. Review of the care plan showed the patients identified problems included the need for skilled teaching of cardiac/circulatory system. The goals listed showed the patient will have decrease in edema, decrease in shortness of breath, and decrease in angina/anginal episodes within the constraints of the disease. There was no documented evidence showing the measurable goals for each of the goals listed. On 11/18/22 at 1042 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and verified the finding. 2. Review of Patient 1's clinical record was initiated on 11/9/22. The clinical record showed the SOC was 6/9/22. The patient was certified for hospice services during the certification period from 9/7/22 to 12/5/22. Review of the care plan showed the patients identified problems included the need for the skilled nurse to provide decubitus wound care. The goal listed showed the patient will verbalize tolerance to decubitus care. However, there was no documented evidence showing the patients measurable pain tolerance. On 11/18/22 at 1151 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and verified the finding.

Based on interview and clinical record review, the hospice failed to ensure the IDG had reviewed and revised the patient's POCs at least every 15 days for two of 17 sampled patients (Patients 3 and 15), creating the risk of not providing appropriate, consistent, and quality care to these patients. --- Findings: 1. Review of Patient 3's clinical record was initiated on 11/9/22. The patient's clinical record showed the SOC was 8/12/22. The patient was certified for hospice services during the certification periods from 8/11/22 to 10/10/22 and 10/11/22 to 12/9/22. Review of the clinical record failed to show documented evidence the IDG reviewed and updated the POC every 15 days. The IDG notes showed the IDG meeting was conducted on 8/30/22, 17 days after the previous IDG meeting on 8/12/22. On 11/18/22 at 1430 hours, an interview and concurrent clinical record review was conducted with RN 1. She was informed and acknowledged the finding. 2. Review of Patient 15's clinical record was initiated on 11/10/22. The clinical record showed the SOC was 2/25/22. The patient was certified for hospice services during the certification periods from 8/24/22 to 10/22/22 and 10/23/22 to 12/21/22. The patient resided in a SNF. The physicians order dated 10/8/22, showed SN visits 1W9 and 2 PRN effective 10/23/22. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 10/26/22, showed SN visits 2W. The SN notes showed the SN conducted one visit instead of two on Week 1 (10/23/21 to 10/29/21) and Week 2 (10/30/22 to 11/5/22). On 11/18/22 at 0945 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 stated the SN visit frequency should be one time a week instead of two. She stated the POC should have been revised to show SN 1W. She was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to ensure the revised POCs included the patient's progress toward goals specified in the POCs for 13 of 17 sampled patients (Patients 2, 4, 5, 6, 7, 9, 11, 12, 13, 14, 15, 16, and 17), creating the risk of not identifying the care needs and providing the necessary care and services to meet the care needs for these patients. --- Findings: Review of the hospice's P&P titled Prioritizing Patient Problems/Needs revised April 2013 showed using the data obtained during the initial, comprehensive, and ongoing hospice assessments, the hospice interdisciplinary group members will develop a list of patient problems and needs with corresponding goals and anticipated target dates for reaching those goals. Review of the clinical records for Patients 2, 4, 5, 6, 7, 9, 11, 12, 13, 14, 15, 16, and 17, showed the revised POCs did not include the patients' progress toward the goals as specified in the POCs. For example: 1. Review of Patient 17's clinical record was initiated on 11/14/22. The clinical record showed the SOC was 6/5/22. The patient was certified for hospice services during the certification periods from 8/4/22 to 10/2/22 and 10/3/22 to 12/1/22. Review of the plan of care for the certification period showed the hospice identified multiple patient care problems such as the patients need for skilled teaching and monitoring the use of oxygen; and the need for skilled teaching of cardiac/circulatory system. Further review of the clinical record showed documented evidence the IDG reviewed the POCs Q 14 days. However, there was no documented evidence showing the POCs included the patient's progress towards the goals for each of the care plan problem identified. On 11/18/22 at 1042 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and verified the finding. 2. Review of Patient 10's clinical record was initiated on 11/14/22. The clinical record showed the SOC was 9/16/21. The patient was certified for hospice services during the certification period from 9/11/22 to 11/9/22. Review of the plan of care for the certification period showed the hospice identified multiple patient care problems such as the patients need for skilled teaching related to respiratory status and bowel incontinence. Further review of the clinical record showed documented evidence the IDG reviewed the POCs Q 14 days. However, there was no documented evidence showing the POCs included the patient's progress towards the goals for each of the care plan problem identified. On 11/18/22 at 1141 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and verified the finding.

Based on interview and record review, the hospice failed to ensure the IDG had maintained the responsibility for directing and supervising the care and services provided for seven of 17 sampled patients (Patient 2, 3, 6, 9, 12, 15, and 17), creating the risk of not addressing the care needs for these patients. --- 6. Review of Patient 17's clinical record was initiated on 11/14/22. The clinical record showed the SOC was 6/5/22. The patient was certified for hospice services during the certification periods from 8/4/22 to 10/2/22 and 10/3/22 to 12/1/22. Review of the recertification orders dated 7/20/22, cited HA visits 1W1 and 3W8 effective on 8/4/22. Review of the recertification orders dated 9/18/22, cited HA visits 3W8 and 2W1 effective on 10/3/22. The Aide Care Plan Report for both certification periods showed to perform vital signs assessments of the patients temperature and respirations. However, review of all the HA notes for both certification periods showed documentation that the patient refused the temperature and respiration assessments. The HA documented that the RN was notified of the patients refusal. Review of the IDG Comprehensive Assessment and Plan of Care Update Report for both certification periods showed no documented evidence the IDG had discussed the patients refusal for the above HA task. The IDG failed to supervise the care and services provided to the patient. On 11/18/22 at 1042 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and verified the finding. Cross reference L 545 example #3. 7. Review of Patient 6's clinical record was initiated on 11/16/22. The clinical record showed the SOC was 9/12/21. The patient was certified for hospice services during the certification periods from 8/8/22 to 10/6/22 and 10/7/22 to 12/5/22. Review of the recertification orders dated 7/24/22, cited HA visits 3W8 and 2W1 effective on 8/8/22. Review of the recertification orders dated 9/22/22, cited HA visits 1W1, 3W8, and 1W1 effective on 10/7/22. The Aide Care Plan Report for both certification periods showed to perform vital signs assessments of the patients temperature, pulse, and respirations. However, review of all the HA notes for both certification periods showed documentation that the patient refused the temperature, pulse, and respiration assessments. The HA documented that the RN was notified of the patients refusal. Review of the IDG Comprehensive Assessment and Plan of Care Update Report for both certification periods showed no documented evidence the IDG had discussed the patients refusal for the above HA task. The IDG failed to supervise the care and services provided to the patient. On 11/18/22 at 1122 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and verified the finding. Cross reference L 545 example #5. 1. Review of Patient 2's clinical record was initiated on 11/9/22. The patient's clinical record showed the SOC was 6/4/20. The patient was certified for hospice services during the certification period from 9/22/22 to 11/20/22. The physicians order dated 9/7/22, showed HA visits 1W1 and 2W8 effective 9/22/22 The Aide Care Plan Report, for the certification period from 9/22/22 to 11/20/22, included the following tasks: temperature, respiration, and pulse Q visit. The HA notes dated 9/22, 9/26, 9/29, 10/3, 10/6, 10/10, 10/13, 10/17, 10/20, 10/24, 10/27, 10/31, 11/3, and 11/7/22, showed the patient refused temperature, respiration, and pulse at the above visits and the RN was notified. The IDG Comprehensive Assessment and Plan of Care Update Report dated 10/9, 10/23, and 11/6/22, showed no documented evidence the IDG had discussed the patients refusal for the above HA task. The IDG failed to supervise the care and services provided to the patient. On 11/18/22 at 1145 hours, a concurrent clinical record review and interview was conducted with RN 1. She was informed and acknowledged the finding. 2. Review of Patient 3's clinical record was initiated on 11/9/22. The patient's clinical record showed the SOC was 8/12/22. The patient was certified for hospice services during the certification periods from 8/11/22 to 10/10/22 and 10/11/22 to 12/9/22. The IDG Comprehensive Assessment and Plan of Care Update Report dated 8/12, and 8/30 /22, showed SN 1W1, 2W1, and 1W7. The IDG Comprehensive Assessment and Plan of Care Update Report dated 9/13/22, showed SN 1W Review of the SN notes showed the RN had no visit during Week 3 (8/21 to 8/27), Week 4 (8/28/22 to 9/3/22), Week 5 (9/4/22 to 9/10/22), and Week 7 (9/18/22 to 9/24/22), instead of one visit. On 11/18/22 at 1430 hours, a concurrent clinical record review and interview was conducted with RN 1. RN 1 stated there were SN missed visits on 8/27 (Week 3), 9/2 (Week 4), 9/8 (Week 5), and (9/24/22 (Week 7). However, there was no documented evidence the physician or IDG was informed of the SN missed visits. She was informed and acknowledged the finding. 3. Review of Patient 9's clinical record was initiated on 11/16/22. The patient's clinical record showed the SOC was 8/13/22. The patient was certified for hospice services during the certification periods from 8/13/22 to 10/11/22 and 10/12/22 to 12/10/22. a. The Aide Care Plan Report, for the certification period from 8/13/22 to 10/11/22, included the following tasks: temperature and respiration Q visit. The HA notes dated 8/19, 8/23, 8/26, 8/30, 9/6, 9/9, 9/13, 9/20, 9/23, 9/27, 9/30, and 10/4/22, showed the patient refused temperature and respiration at the above visits. * However, the IDG Comprehensive Assessment and Plan of Care Update Report dated 8/24, 9/7, 9/21, and 10/1/22, showed no documented evidence the IDG had discussed the patients refusal for the above HA task. b. The Hospice Certification and Plan of Care, during the certification period from 8/13/22 to 10/11/22, showed SN visit 1W1, 2W8, and 1W1. Review of the SN notes showed the RN had one visit instead of two visits during Week 2 (8/14/22 to 8/20/22). On 11/18/22 at 1000 hours, a concurrent clinical record review and interview was conducted with RN 1. RN 1 stated there was a SN missed visit on 8/14/22 (Week 2). However, there was no documented evidence the physician or IDG was informed of the missed visit. She was informed and acknowledged the findings. 4. Review of Patient 12's closed clinical record was initiated on 11/15/22. The patient's closed clinical record showed the SOC was 6/28/22. The patient was certified for hospice services during the certification periods from 6/28/22 to 9/25/22. a. The SN note dated 6/28/22, showed the patient/PCG was open to volunteer services to meet social/family support needs. Documentation showed the Volunteer Coordinator notified of request. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 7/5/22, showed the IDG had discussed and followed through the request of volunteer as per SN note 7/5/22. On 11/18/22 at 1205 hours, a concurrent clinical record review and interview was conducted with RN 1. She was informed and acknowledged the finding. b. The Hospice Certification and Plan of Care, during the certification period from 6/28/22 to 9/25/22, showed Chaplain visit 1W1 Further review of the clinical record showed the Chaplain had no visit during Week 1 (6/28/22 to 7/1/22), instead of one visit. On 11/18/22 at 1205 hours, a concurrent clinical record review and interview was conducted with RN 1. She stated there was a Chaplain missed visit on 7/1/22. However, there was no documented evidence the physician or IDG was informed of the missed visit. She was informed and acknowledged the finding. 5. Review of Patient 15's clinical record was initiated on 11/10/22. The clinical record showed the SOC was 2/25/22. The patient was certified for hospice services during the certification periods from 8/24/22 to 10/22/22 and 10/23/22 to 12/21/22. The patient resided in a SNF. The physicians order dated 8/30/22, showed HA visit 2W1 and 3W6 effective 9/4/22. The HA notes showed the HA conducted one visit instead of three on Week 6 (9/25/22 to 10/1/22), no visit instead of three on Week 7 (10/2/22 to 10/8/22), two visit instead of three on Week 8 (10/9/22 to 10/15/22) and Week 9 (10/16/22 to 10/22/22) On 11/18/22 at 1205 hours, a concurrent clinical record review and interview was conducted with RN 1. RN 1 stated there were HA missed visits on 9/28 and 9/30/22 on Week 6; 10/3, 10/5, and 10/7/22 on Week 7; 10/11/22 on Week 8; and 10/19/22 on Week 9. * However, there was no documented evidence the physician or IDG was informed of the missed visits. On 11/18/22 at 945 hours, a concurrent clinical record review and interview was conducted with RN 1. She was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to coordinate the patients care needs for two of 17 sampled patients (Patients 1 and 7). This failure created the risk of not providing the necessary care and services to these patients. --- Findings: Review of the hospice's P&P titled Interdisciplinary Group Coordination of Care revised April 2013 showed contracted personnel will participate in preparation of the plan of care; submit documentation of services provided, including clinical notes, schedule of visits, and patient evaluations at least twice a week; and participate in interdisciplinary group meetings. Care provided by contracted services will be monitored by the interdisciplinary group to ensure compliance with the plan of care. Continuity of care will be maintained throughout the patient's course with hospice. Exchange of information between hospice staff and contracted providers will be documented in the clinical record. 1. Review of Patient 1's clinical record was initiated on 11/9/22. The clinical record showed the SOC was 6/9/22. The patient was certified for hospice services during the certification period from 9/7/22 to 12/5/22. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/13/22, showed an order for the PT to evaluate and treat the patient. Further review of the clinical record showed no documented evidence a PT had evaluated and provided treatment to Patient 1. On 11/18/22 at 1151 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was asked if the PT was able to evaluate the patient. The DPCS stated the PT did evaluate and treat the patient. When asked to show the assessments and documentation of treatment, the DPCS verified the hospice did not keep the PT assessments and documentation because the PT was contracted. 2. Review of Patient 7's clinical record was initiated on 11/15/22. The clinical record showed the SOC was 7/8/21. The patient was certified for hospice services during the certification period from 11/5/22 to 1/3/23. Review of the physicians order dated 10/11/22, showed an order for PT treatment and evaluation. Further review of the clinical record showed no documented evidence a PT evaluated and provided treatment to Patient 7. On 11/18/22 at 1059 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed of the finding. The DPCS verified the patient was receiving PT services; however, the PT did not send the notes to hospice regularly.

Based on interview and record review, the hospice failed to ensure the QAPI program showed measurable improvement in indicators related to improved palliative outcomes and hospice services. This created the risk of not improving the care and services provided to the patients. --- Findings: Review of the hospice's P&P titled Quality Assessment Performance Improvement Program dated 1/1/18, showed the QAPI program must at least be capable of showing measurable improvement in indicators related to improved palliative outcomes and hospice services. The Board of Directors will ensure that the hospice-wide QAPI efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated for effectiveness. Review of the hospice's QAPI programs for the years 2020, 2021, and 2022 was initiated on 11/17/22. The QAPI program showed the hospice performed the same PI projects each year from 2020 to 2022 which included pain analysis and treatment analysis for patients with anxiety, depression, dyspnea, nausea, and opioid medications. The QAPI program for 2020, 2021, and 2022 showed the hospice collected data and tracked each PI project every quarter. However, there was no documented evidence of measurable improvement and action plans were implemented to address the data collected in order to improve care and services. On 11/18/22 at 0954 hours, an interview and concurrent record review was conducted with the DPCS. The DPCS was informed and verified the finding.

Based on interview and record review, the hospice failed to measure, analyze, and track the quality indicators, including the adverse events and other aspects of performance that enabled the hospice to assess processes of care, hospice services, and operations. This created the risk of not identifying areas for performance improvement to improve care and services provided to the patients. --- Findings: Review of the hospice's P&P titled Performance Improvement Process: Data Aggregation and Analysis dated 11/1/08, showed the hospice will implement a systematic process to analyze collected data on an ongoing basis by a QAPI committee. Aggregated data are analyzed in order to make judgements about whether the design specifications for processes were met; the level of performance and stability of important existing processes; opportunities for improvement; actions to improve the performance of processes; whether changes in the processes resulted in improvement; and effectiveness and safety of services, including competency of staff, promptness of service delivery appropriateness of responses to patient and family problems. Review of the hospice's QAPI programs for the years 2020, 2021, and 2022 was initiated on 11/17/22. The QAPI program showed the hospice performed the same PI projects each year from 2020 to 2022 which included pain analysis and treatment analysis for patients with anxiety, depression, dyspnea, nausea, and opioid medications. The data was collected for each PI project and an analysis report was created quarterly. However, the analysis report only showed the visual representation of the data collected. There was no documented evidence a meaningful analysis of the data collected nor was there any documentation showing the preventive actions implemented and the evaluation of whether the current practices were effective in improving the overall care and services provided to the patients. On 11/18/22 at 0954 hours, an interview and concurrent record review was conducted with the DPCS. The DPCS verified the finding.

Based on interview and record review, the hospice failed to ensure the PI activities focused on high risk, high volume, and problem-prone areas as per the hospice's P&P. This failure had the potential to adversely affect the quality of care provided to the patients. --- Findings: Review of the hospice's P&P titled Quality Assessment Performance Improvement Program dated 1/1/18, showed hospice leaders and the QAPI Committee will prioritize performance improvement activities. Criteria in setting priorities will include selecting high-risk, high-volume, or problem-prone process to monitor and consider incidence, prevalence, and severity of problems in those areas. Review of the hospice's QAPI programs for the years 2020, 2021, and 2022 was initiated on 11/17/22. The QAPI program showed the hospice focused on the same PI activities each year from 2020 to 2022 which included pain analysis and treatment analysis for patients with anxiety, depression, dyspnea, nausea, and opioid medications. On 11/17/22 at 1308 hours, an interview and concurrent record review was conducted with the DPCS. The DPCS was asked what were some of the high risk, high volume, and problem-prone areas identified by the hospice from 2020 to 2022. The DPCS stated the hospice highlighted infection control as a PI project because it was an ongoing issue. The DPCS also stated they had an ongoing issue with timely completion of documentation and coordination of care among other things. When asked why these issues were not included as part of the PI projects from 2020 to 2022, the DPCS replied because corporate was the one who picked the PI projects for the hospice. The DPCS verified the PI projects chosen by corporate did not include the high risk, high volume, and problem-prone areas identified by the hospice.

Based on interview and record review, the hospice failed to document the reason for conducting the PI projects and measurable progress achieved on these projects as per the hospice's P&P. This failure created the risk of not effectively evaluating the outcomes of the PI projects to improve the care and services provided by the hospice's staff. --- Findings: Review of the hospice's P&P titled Quality Assessment Performance Improvement Program dated 1/1/18, showed the hospice must document what PI projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. The hospice must document corrective action to ensure that improvements are sustained over time. Review of the hospice's QAPI programs for the years 2020, 2021, and 2022 was initiated on 11/17/22. The QAPI program showed the hospice focused on the same PI projects each year from 2020 to 2022 which included pain analysis and treatment analysis for patients with anxiety, depression, dyspnea, nausea, and opioid medications. Further review of the QAPI programs and meeting minutes showed no documented evidence of the IDG discussing the reason for conducting these projects and the measurable progress achieved on these projects. On 11/18/22 at 0954 hours, an interview and concurrent record review was conducted with the DPCS. The DPCS verified the finding and was unable to provide documentation as to why the hospice decided to conduct these PI projects and the measurable progress achieved. When asked why these projects were selected as part of the QAPI program, the DPCS stated corporate was the one who decided which PI projects the hospice conducted.

Based on interview and document review, the hospice failed to maintain the coordinated agency-wide program for the surveillance identification, prevention, control, and investigation of the infections that included a plan for implementing the appropriate actions that were expected to result in improvement and infection prevention. This created the risk of spread of the infections. --- Findings: Review of the hospice's P&P titled Evaluating and Maintaining Records of Infections Among Patients dated 11/2013 showed: - All patients with new, actual, or suspected infection will have a patient infection report completed within 24 hours of discovery. If trends are discovered, target surveillance or problem-oriented surveillance may be initiated for specific high-risk patient populations if high volume, problem-prone areas are identified. - Targeted Surveillance focuses on specific populations or procedures, such as patients with enteral feedings who suffer higher-than-expected incidence of diarrhea - Problem-oriented surveillance measures the occurrence of a specific infection in multiple patients. Also called outbreak-response surveillance - The Case Manager or nurse caring for the patient in his/her absence should complete the Infection Identification Patient Report within 24 hours of discovering the infection - After completion, the original form will be sent to the Performance Improvement Coordinator, and a copy will be submitted to the appropriate personnel for follow-up - The Performance Improvement Coordinator summarizes, trends, and analyzes the reports. The breakdown and summary may include but will not be limited to number of infection types, sources of infection, diagnosis, age/sex of patients, family/caregiver, pathogens (if identified), and follow-up taken. - The Performance Improvement Coordinator, in conjunction with the Program Supervisor, will investigate possible causal factors and recommend appropriate action to contain the transmission of infection. Actions may include implementing target or problem surveillance to aid in identifying causal factors and appropriate recommendations. - Information from the summary, analysis, and discussion will be used as part of the organization's risk analysis and annual evaluation of the organization's infection prevention and control activities. A concurrent interview and record review was conducted with the DPCS on 11/17/22 at 1000 hours. The DPCS stated if there was a report of a patient infection, the clinician would document the infection on an Infection Report and inform the supervisor. She stated there were three infection control meetings held to discuss infection control which included with the RNs Q Monday, once a month with the IDG, and one with QAPI. She stated the monthly meeting with the IDG would include pulling the ";QI Event Summary Report" once a month, discuss each patients infection case, and document in the patients record. The DPCS further stated the hospices corporate would send an infection control report for a specified time frame which was summarize by an audit company. She stated the infection control report from corporate would include the percentages of the different types of hospice infection and the percentages from the national cases which were shown in two pie charts. She stated one pie chart showed some of the percentages of each type of infection for the hospice infection cases and the other pie chart showed some of the percentages of each type of infection from the national cases. She stated the hospice should have a lower percentage of infection in comparison to the national cases. Review of the agency's infection control reports (summarized by an audit company) from July 2020 to August 2022 was conducted on 11/17/22. The infection control reports had information on the number of cases of each type of infection of the hospice for a specific time frame. The infection control reports on each time frame showed two pie charts. a. The 2020 infection control reports showed the following information: - The infection control report from 7/1/20 to 8/31/20, showed there were nine cases of infection, including four UTIs (44% of the infection cases), one wound infection, three respiratory infections (33%), no systemic infection, and one as ";other" infection. Documentation showed the national cases is as follows: UTI was 36%, respiratory infection 20%, and ";other" infection 33%. - The infection control report from 9/1/20 to 12/31/20, showed there were 26 cases of infection, including 17 UTIs (65% of the infection cases), seven wound infections (27%), two as ";other" infections, and no respiratory and systemic infection. Documentation showed the national cases is as follows: UTI was 35%, respiratory infection 24%, and ";other" infection 31%. b. The 2021 infection control reports showed the following information: - The infection control report from 1/1/21 to 4/30/21, showed 37 cases of infection, including 24 UTIs (65% of the infection cases), two wound infections, three respiratory infections, eight as ";other" infection (22%), and no systemic infection. Documentation showed the national cases is as follows: UTI was 38%, respiratory infection 20%, and ";other" infection 30%. - The infection control report from 5/1/21 to 8/31/21, showed 38 cases of infection, 26 UTIs (68% of the infection cases), five wound infections, three respiratory infections, four as ";other" infections, and no systemic infection. Documentation showed the national cases is as follows: UTI was 39%, respiratory infection 19%, and ";other" infection 29%. - The infection control report from 9/1/21 to 12/31/21 showed 37 cases of infection, including 20 UTIs (54% of the infection cases), seven wound infections (19%), five respiratory infections, five as ";other" infections, and no systemic infection. Documentation showed the national cases is as follows: UTI was 38%, respiratory infection 22 %, and ";other" infection 28%. c. The 2022 infection control report showed the following information: - The infection control report from 1/1/22 to 4/30/22, showed 51 cases of infection, including 29 UTIs (57% of infection cases), six wound infections, five respiratory infections, no systemic infection, and 11 as ";other" infections (22%). Documentation showed the national cases is as follows: UTI was 37%, respiratory infection 24 %, and ";other" infection 29%. - The infection control report from 5/1/22 to 8/31/22, showed 54 cases of infection, including 32 UTIs (59% of infection cases), 11 wound infections (20%), four respiratory infections, seven as ";other" infections, and no systemic infection. Documentation showed the national cases is as follows: UTI was 39%, respiratory infection 21 %, and ";other" infection 29%. * Further review of the infection control program showed no documented evidence the hospice had analyzed the data, investigated for possible causes of infections, and implemented specific actions to minimize infections. On 11/18/22 at 1445 hours, the DPCS was informed of the finding. The DPCS stated she delegated a hospice staff to track and log infection cases starting September 2022.

Based on interview and record review, the hospice failed to ensure the HAs provided the services in accordance with the POCs of four of 17 sampled patients (Patients 7, 10, 13, and 14). This failure created the risk of not providing appropriate, consistent, and quality care to the patients. --- Findings: Review of the clinical records for Patients 7, 10, 13, and, 14, showed the HAs failed to provide the services in accordance with the POCs. For example: 1. Review of Patient 10's clinical record was initiated on 11/14/22. The clinical record showed the SOC was 9/16/21. The patient was certified for hospice services during the certification period from 9/11/22 to 11/2/22. Review of the recertification orders dated 8/27/22, cited HA visits 2W8 and 1W1 effective on 9/11/22. Review of the Aide Care Plan Report showed to assess the patients temperature, respirations, pulse, and last bowel movement every visit. Review of the HA Notes showed the HA visited the patients home as cited in the POC. However, there was no documented evidence the HA had checked the patients last bowel movement during the HA visits within the certification period. On 11/18/22 at 1141 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and verified the finding. 2. Review of Patient 14's closed clinical record was initiated on 11/15/22. The clinical record showed the SOC was 6/3/21. The patient was certified for hospice services during the certification period from 12/1/21 to 1/29/22. Review of the recertification orders dated 11/16/21, cited HA visits 1W1 and 2W8 effective on 12/1/21. Review of the Aide Care Plan Report showed to assess the patients temperature, respirations, and pulse every visit. Review of the HA Notes showed the HA visited the patients home as cited in the POC. However, there was no documented evidence showing HA consistently checked the patients temperature, respirations, and pulse during each visit. For example, on 12/7/21, the HA documented ";N" for ";no" to represent the temperatures, respirations, and pulses were not assessed. On 11/18/22 at 1002 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS was informed and verified the finding.

Based on interview and record review, the hospice's Administrator failed to be responsible for the day to day operations of the organization and maintain administrative and supervisory responsibility for all care provided as follows:- The Administrator failed to ensure the implementation of the hospice's P&P related to IDG attendance for 11 of 17 sampled patients (Patients 1, 2, 3, 5, 6, 7, 9, 12, 14, 15, and 16).- The Administrator failed to ensure the required members of the QAPI committee were in attendance during the QAPI meetings as per the hospices P&P. - The Administrator failed to ensure the TB testing was performed for the Medical Director, Associate Medical Director, LVNs, and HA as per hospice's written agreement and P&P.- The Administrator failed to ensure the performance evaluations were completed for the LVN as per hospice's P&P.- The Administrator failed to ensure the written agreements included the services, roles and responsibilities of the contracted agencies. These failures had the potential to negatively impact the hospice's operational performance. --- 3. Review of the facility's P&P titled Tuberculosis Exposure Control Plan updated, showed all personnel will be tested for TB according to the risk assessment identification for which personnel have potential exposure to TB and in accordance with federal, state and or local regulations. According to Standards of Quality Hospice Care, 2005 under Section 6.3 A (1) (2) (3) showed all persons providing services shall have a health examination by a physician or physician's assistant six months prior to employment or within 14 days of the date of employment. The initial health examination shall include a tuberculosis screening. Hepatitis B vaccinations will be offered to all employees whose jobs involve the risk of directly contacting blood or other potentially infectious materials consistent with OSHA standards. a. Review of the employee file for HA 1 showed, the date of hire was 11/9/21. The TB testing was performed on 5/27/22. However, the TB testing was performed more than 14 days from the date of employment. b. Review of the employee file for LVN 1 showed the date of hire was 4/15/19. The TB testing was performed on the following dates: - On 6/19/20 which was more than six months prior to the date of hire. - On 7/15/19 which was more that 14 days from the date of employment. c. Review of the employee file for LVN 2 showed the date of hire was 2/15/21. The TB testing was performed on the 6/30/21 However, the TB testing was performed more that 14 days from the date of employment. 4. Review of the hospice's P&P titled Initial Competency Assessment undated, showed the organization ensures that the competency of all personnel is assessed on hire, prior to providing care. Review of the employee file for HA 1 showed, the date of hire was 11/9/21. The employee's initial competency evaluation was performed on 12/7/22 However, the employee visited the patient on 12/6/22 which was performed prior to completion of the initial competency assessment as per facility's P&P. 5. Review of the hospice's P&P titled Performance Evaluation undated, showed the performance evaluations will be completed and dated on all personnel annually based on the personnels' evaluation date. Review of the employee file for LVN 2 showed the date of hire was 2/15/21, the performance evaluation was completed on 1/27/21. However, the employee file failed to show documented evidenced the performance evaluation was completed a year after the initial evaluation as per facility's P&P. 6. Review of the Associate Medical Director and Professional Services Agreement dated 6/20/2018, showed the physician will adhere to any and all hospice P&P so long as such P&P are made available to the Physician, and federal and state laws and regulations applicable to Physicians' provision of services within the hospice. Further, services shall be performed in compliance with the applicable federal and state licensure and Medicare and Medicaid certification requirements, including the Medicaid conditions of participation. Review of the Associate Medical Director file showed the date of hire was 7/28/2018. However, the employee file failed to show documented evidenced of the TB testing was performed per hospice's agreement, P&P and state regulations. In addition, review of the employee file failed to show documented evidenced of the hepatitis vaccine. 7. Review of the Medical Director personnel file showed the date of hire was 1/21/2016. The TB testing result was documented on 3/29/22. However, the employee file failed to show the Medical Director had completed the TB testing prior to date of hire, 14 days from the date of hire and for the years 2017, 2018, 20/19, 2020 and 2021. In addition, review of the employee file showed the Hepatitis vaccine document dated 1/21/21. However, there were no documented evidenced the hepatitis vaccine was offered on the years 2017, 2018, 2019 and 2020. On 11/18/22 at 0805 hours an interview with concurrent document review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. 8. According to Standards of Quality Hospice Care, 2005 under Article 6, Section 6.2 B (a) (c)(1) (2) (3) (4) (5) (6) (7) (d) (e) (f) (g) and (h) Contractual Services when, program services are not provided directly by employees there shall be a written agreement defining the nature and scope of services provided. The agreement shall address, but not be limited to the roles and responsibilities of the program and contracted individual or organization in the patient/family admission process, patient/family assessment, the development, review, and revision of POCs, interdisciplinary team conferences, scheduling of visits or hours, discharge planning, bereavement, and submission of documentation of services provided to the agency. Review of the written agreements between the hospice and contracted providers was conducted on 11/16/22, and showed the following: * Review of the written agreement between the hospice and the Contractor 1 providing pharmacy services failed to include the rights and responsibilities of the hospice and pharmacy for the evaluation of care services. Further review of the written agreement between the hospice and the Contractor 1 providing pharmacy services failed to include the roles and responsibility to include submission of documentation of the services provided. * Review of the written agreement between the hospice and the Contractor 3 providing pharmacy services failed to show the signature of the representative of the contracted pharmacy. In addition, the written agreement between the hospice and the Contractor 3 providing pharmacy services failed to include the effectivity date of the services provided. * Review of the written agreements between the hospice and Contractor 4 providing PT/OT services failed to include the rights and responsibilities for the coordination, supervision and evaluation of services. Further review of the written agreement between the hospice and the Contractor 4 providing PT/OT services failed to include the roles and responsibilities for patient/family admission process, patient /family assessment, development, review of, revision and management of the plan of care, interdisciplinary team conferences, scheduling visit hours, discharge planning and bereavement follow up. In addition, the agreement failed to include the procedure for charges and reimbursement, term of the agreement and the condition for its renewal or termination and education requirements. * Review of the written agreements between the hospice and Contractor 5 providing PT/OT services failed to include the roles and responsibilities for scheduling of visit hours, discharge planning and bereavement follow up. Further review of the agreement between the hospice and the Contractor 5 providing PT/OT services failed to include submission of documentation of the services provided. * Review of the written agreements between the hospice and Contractor 6 providing DME and RT services failed to show the roles and responsibilities for scheduling of visit hours, discharge planning and bereavement follow-up. * Review of the written agreements between the hospice and contracted Associate Medical Director failed to show the roles and responsibilities for scheduling of visit hours, discharge planning and bereavement follow-up. * Review of the written agreements between the hospice and Contracted 8 providing Ambulance services failed to include the rights and responsibilities for the coordination, supervision and evaluation of care services. In addition, review of the agreement between the hospice and the Contractor 8 providing Ambulance services failed to show the effective date of the contract. * Review of the written agreements between the hospice and Contractor 9 providing laboratory services failed to include the rights and responsibilities for the coordination, supervision and evaluation of care services. In addition, review of the written agreement between the hospice and the Contractor 9 providing laboratory services failed to show the signature of the laboratory's representative. * Review of the written agreements between the hospice and Contractor 10 providing peripheral venipuncture and insertion of specialty catheter services failed to include the rights and responsibilities for the coordination, supervision and evaluation of care services. In addition, review of the written agreement between the hospice and the Contractor 9 failed to show the signature of the hospice's and the Contractors' 10 representative. On 11/18/22 at 1032 hours an interview with concurrent document review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. Review of the hospice's P&P titled Administrative Qualifications and Responsibilities revised date April 2013, showed the hospice's administrative position description will clearly define specific responsibilities and include at least the organization and direction of the operation to assure availability and provision of care and services, and implementing the organizations policies and procedures. Review of the hospice's P&P titled Interdisciplinary Group Meeting revised date April 2013, showed members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice clinical supervisor. Review of the clinical records for Patients 1, 2, 3, 5, 6, 7, 9, 12, 14, 15, and 16, showed the hospice failed to ensure the IDG members had electronically signed for their participation during the IDG Comprehensive and Plan of Care Update conducted at least Q 14 days. For example: 1a. Review of Patient 2's clinical record was initiated on 11/9/22. The patient's clinical record showed the SOC was 6/4/20. The patient was certified for hospice services during the certification period from 9/22/22 to 11/20/22. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/25, 10/9, 10/23, and 11/6/22, showed no documented evidence of the hospice physician and chaplains electronic signature. On 11/18/22 at 1145 hours, a concurrent clinical record review and interview was conducted with RN 1. She was informed and acknowledged the finding. b. Review of Patient 3's clinical record was initiated on 11/9/22. The patient's clinical record showed the SOC was 8/12/22. The patient was certified for hospice services during the certification periods from 8/11/22 to 10/10/22 and 10/11/22 to 12/9/22. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report showed the following information: - On 8/12/22, showed no documented evidence of the hospice physician and chaplains electronic signature. - On 8/30 and 9/13/22, showed no documented evidence of the hospice physicians electronic signature. - On 9/27/22, showed was no documented evidence of the hospice physician and RNs electronic signature. On 11/18/22 at 1430 hours, a concurrent clinical record review and interview was conducted with RN 1. She was informed and acknowledged the finding. c. Review of Patient 1's clinical record was initiated on 11/9/22. The clinical record showed the SOC was 6/9/22. The patient was certified for hospice services during the certification period from 9/7/22 to 12/5/22 Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/3, 9/27, 10/11, 10/25, and 11/8/22, showed no documented evidence of the physicians electronic signature. On 11/18/22 at 1151 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and verified the finding. d. Review of Patient 14's clinical record was initiated on 11/15/22. The clinical record showed the SOC was 6/3/21. The patient was certified for hospice services during the certification period from 1/30/22 to 2/1/22. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 2/1/22, showed no documented evidence of the MSW and physicians electronic signature. On 11/18/22 at 1002 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and verified the finding. 2. Review of the hospice's P&P titled Quality Assessment Performance Improvement Program dated 1/1/18, showed at a minimum, the QAPI committee will consist of the administrator, the supervising nurse, and individuals representing the scope of services provided by the agency. The QAPI committee will meet at least twice a year or more often if needed and will maintain a written record of the meetings with appropriate signatures. Review of the QAPI Meeting Minutes for the years 2020, 2021, and 2022, showed the QAPI committee met five times per year. However, there was no documented evidence the Administrator and the supervising nurse were in attendance as required per the P&P on 2/6/20, 4/1/20, 6/4/20, 9/1/20, 4/20/21, 5/8/21, 3/1/22, 5/6/22, and 7/8/22. On 11/18/22 at 0954 hours, an interview and concurrent record review was conducted with the DPCS. The DPCS verified the finding.

Based on interview and record review, the hospice failed to ensure the clinical records were complete and accurate for four of 17 sampled patients (Patients 2, 4, 12, and 17). This failure created the risk of the patients receiving substandard care and disrupting the continuity of care due to incomplete and inaccurate documentation and information in their clinical records. --- 4. Review of Patient 17's clinical record was initiated on 11/14/22. The clinical record showed the SOC was 6/5/22. The patient was certified for hospice services during the certification period from 8/4/22 to 10/2/22. Review of the POC showed a care plan problem addressing the patients need for skilled teaching and monitoring the use of oxygen.Review of the Visit Note Report dated 8/8/22, showed the SN documented the patient had an oxygen saturation of 95% on four liters of oxygen. However, the SN documented the patient was using 3.5 liters of oxygen per minute under the respiratory assessment section which was inconsistent.In addition, on 9/1/22, the SN documented the patient had an oxygen saturation of 94% on room air. However, the SNs narrative showed the patient was on continuous oxygen via the nasal cannula. On 11/18/22 at 1042 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and verified the finding. Findings: 1. Review of Patient 2's clinical record was initiated on 11/9/22. The patient's clinical record showed the SOC was 6/4/20. The patient was certified for hospice services during the certification period from 9/22/22 to 11/20/22. The physicians order dated 9/7/22, showed HA visits 1W1 and 2W8 effective 9/22/22. The Aide Care Plan Report, for the certification period from 9/22/22 to 11/20/22, showed HA visit 1W1 and 3W12. * However, the frequency of HA visit was not consistent. On 11/18/22 at 1145 hours, a concurrent clinical record review and interview was conducted with RN 1. RN 1 stated the correct frequency of the HA visit was the physicians order dated 9/7/22, which was 1W1 and 2W8 effective 9/22/22. She was informed and acknowledged the findings. 2. Review of Patient 4's clinical record was initiated on 11/16/22. The patient's clinical record showed the SOC was 6/21/22. The patient was certified for hospice services during the certification period from 9/19/22 to 11/17/22. The Aide Care Plan Report, during the certification period from 9/19/22 to 11/17/22, included the following task: date of last BM Q visit. The HA note dated 9/22, 10/4, 10/6, 10/11, 10, 14, 10/18, 10/19, 10/25, 10/27, 11/1, 11/3, 11/8, and 11/10/22, showed the task was completed. However, there was no documented evidence of the date of the patients last BM. On 11/18/22 at 1400 hours, a concurrent clinical record review and interview was conducted with RN 1. She was informed and acknowledged the finding. 3. Review of Patient 12's closed clinical record was initiated on 11/15/22. The patient's closed clinical record showed the SOC was 6/28/22. The patient was certified for hospice services during the certification periods from 6/28/22 to 9/25/22. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 7/19/22, showed the patients wound on toes persists and currently receiving treatment. Further review of the clinical record showed no documented evidence of a wound treatment to the patients toes. On 11/18/22 at 1205 hours, a concurrent clinical record review and interview was conducted with RN. She was informed and acknowledged the finding.

Based on interview and record review, the hospice Administrator failed to be responsible for the day-to-day operations, creating the increased risk of substandard of healthcare outcomes to the patients' receiving hospice services. --- Findings: The hospice's P&P titled Administrative Qualifications and Responsibilities (undated) showed the purpose of the P&P is to outline the authority and responsibility for overall administration and management of the facility. The procedure includes the facility will maintain administrative and supervisory responsibility for all care provided through contracted individuals or vendors. a. Review of the written agreement of the hospice with contracted SNF 3 was initiated on 11/16/22. The agreement was entered on 3/4/21, and signed by the hospice Executive Vice President of Operations. However, the agreement was not signed by SNF 3's representative. b. Review of the written agreement of the hospice with the contracted hospital was initiated on 11/16/22. The agreement was entered on 3/6/20. The agreement was signed by the contracted hospitals' representative. However, the agreement was not signed by the facility's Executive Vice President of Operations. On 11/18/22 at 1032 hours, an interview with concurrent document review was conducted with the Administrator. The Administrator was informed and acknowledged the findings.

Based on interview and record review, the hospice failed to coordinate the POC and care and services for one of 17 sampled patients (Patient 15) with the SNF. This failure created the risk of not providing appropriate, consistent, and quality care to this patient. --- Findings: 1. Review of Patient 15's clinical record was initiated on 11/10/22. The clinical record showed the SOC was 2/25/22. The patient was certified for hospice services during the certification periods from 8/24/22 to 10/22/22 and 10/23/22 to 12/21/22. The patient resided in a SNF. The POC, for the certification period 10/23/22 to 12/21/22, showed the patient's identified problems included the need for hospice skilled nurse evaluation, additional visits to be performed; altered comfort; altered sensory/neurological status; need for skilled teaching on levels of consciousness; altered genitourinary; need for skilled teaching related to urinary incontinence; altered gastrointestinal; need for skilled teaching related to bowel incontinence; need for other disciplines; need for medical social worker; need for chaplain; need for hospice standing order; need for skilled administration of pain medication; need for ";O/A" of sensory/neurological status, need for MSW evaluation, need for additional visits as required; evaluation of patient/family mental coping and emotional stability; patient declining status and anticipated imminent death. The goals were established for these identified problems. A joint home visit was conducted with HA 2 on 11/10/22 at 0915 hours, to the SNF where Patient 15 resided. During the review of Patient 15's SNF clinical record showed the identified problem in the POC at the SNF was not consistent with the POC developed by the IDG at the hospice. The POC at the SNF included a care plan problem addressing the patient's seizure disorder related to unknown etiology; at risk for falls and actual fall at home related to gait/balance problems; impaired cognitive function/dementia or impaired thought processes related to dementia; the patient's nutritional problem or potential nutritional problem; the patient's use of antianxiety medications for verbalization of anxiety; and ADL self-care deficit related to disease process. The IDG failed to coordinate with the SNF to consistently address the identified problems in the POC at the SNF, as well as the hospice to ensure consistent care provided to meet the patient's needs. On 11/18/22 at 945 hours, an interview and concurrent clinical record review was conducted with RN 1. She was informed and acknowledged the finding.

Based on interview and record review, the hospice failed to develop the P&P addressing the tracking and securing documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment, thus creating a risk of not providing appropriate guidelines to the facility's staff. --- Findings: Review of the hospice's P&P titled COVID-19 Vaccine (undated) showed the P&P did not include a process on tracking and securing documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment. On 11/18/22 an interview with concurrent document review was conducted with the HR Assistant and Intake Coordinator. They were asked if the P& P included a process of tracking and securing the vaccination status of staff for whom Covid-19 vaccine were temporarily delayed due to acute illness and individuals who received monoclonal antibodies or convalescent plasma. The Intake Coordinator replied it was not included in the P&P and acknowledged the finding.