Every finding on record at Wings of Hope Hospice

Based on record review and interview, the agency failed to ensure the comprehensive assessment included a review of the patient's prescription and over the counter drugs to determine medication interactions or any adverse effects for 5 (P-14, P-15, P-17, P-18, P-19) of 19 records reviewed, resulting in the potential for harmful medication effects for the current 75 patients. Findings include: --- P-14: This patient elected hospice on 3/5/24 with a terminal diagnosis of a leaking abdominal aortic aneurysm. The comprehensive assessment completed by the nurse on 3/5/24, documents in the area for medication profile review that the patient has a new or changed medication described as Morphine 20 mg/ml oral concentrate. During review of the clinical record on 2/4/25, a medication interaction report was generated utilizing the agency's software. The report indicates there are severe interactions between the patient's following medications: Haloperidol and Morphine. There was no documentation to indicate the nurse was aware of the severe interactions and no documentation to indicate the physician was informed of the severe interactions. The findings were reviewed with RN-K (registered nurse/quality assurance/education) during an interview on 2/7/25 at 10:30 a.m. RN-K explained that the pharmacy gives notice of interactions to the medical director who has to approve the medications. There was no documented evidence the pharmacy notified the medical director of the severe interactions. The agency's current policy titled, Comprehensive Assessment No. 1-014 (approved 8/31/23) states, there is a review of current medications, over-the-counter medications, supplements, and herbal remedies to identify actual or potential drug interactions. The policy failed to detail the review by the pharmacy and notification of the physician. P-15: This patient elected hospice on 1/1/25 with terminal diagnoses of lung and brain cancer. The comprehensive assessment completed by the nurse on 1/1/25, documents in the area for medication profile review that new/changed medications were identified and the medication profile updated. During review of the clinical record on 2/4/25, a medication interaction report was generated utilizing the agency's software. The report indicates there are 13 severe interactions between the patient's medications. There was no documentation to indicate the nurse was aware of the severe interactions and no documentation to indicate the physician was informed of the severe interactions. P-17: This patient elected hospice on 6/19/24 with a terminal diagnosis of liver cancer with ascites (excess fluid in abdominal cavity). The comprehensive assessment completed by the nurse on 6/19/24, documents in the area for medication profile review that no issues were identified. During review of the clinical record on 2/6/25, a medication interaction report was generated utilizing the agency's software. The report indicates there are 2 severe interactions between the patient's medications. There was no documentation to indicate the nurse was aware of the severe interactions and no documentation to indicate the physician was informed of the severe interactions. P-18: This patient elected hospice on 1/19/25 with a terminal diagnosis of leukemia. The comprehensive assessment completed by the nurse on 1/19/25, documents in the area for medication profile review there was no evidence of change since last review. During review of the clinical record on 2/6/25, a medication interaction report was generated utilizing the agency's software. The report indicates there are 3 severe interactions between the patient's medications. There was no documentation to indicate the nurse was aware of the severe interactions and no documentation to indicate the physician was informed of the severe interactions. P-19: This patient elected hospice on 12/27/24 with a terminal diagnosis of encephalopathy (change in brain function). The comprehensive assessment completed by the nurse on 12/27/24, documents in the area for medication profile review there was no evidence of change since last review. During review of the clinical record on 2/6/25, a medication interaction report was generated utilizing the agency's software. The report indicates there are 2 severe interactions between the patient's medications. There was no documentation to indicate the nurse was aware of the severe interactions and no documentation to indicate the physician was informed of the severe interactions.

Based on record review and interview, the Hospice failed to ensure the comprehensive assessment included an initial bereavement assessment that identified all who would be affected by the patient's death in 8 (P-1, P-2, P-3, P-4, P-9, P-10, P-17, P-18) records, from a total of 19 records reviewed resulting in the potential for unmet bereavement care needs. Findings included: --- **Policy No. 1-021 titled ";Bereavement Assessment" (approved 8/31/2023) stated, ";The hospice bereavement plan of care will be developed based on an initial assessment of the patient and family/caregiver needs, during the course of care, and at the time of the patients death as part of the comprehensive assessment." P-1: This 83-year-old patient was admitted to this hospice agency on 4/13/24 with the terminal diagnosis of a malignant neoplasm of the left breast (breast cancer) and an unspecified intestinal obstruction. During record review on 2/5/25, it was noted the initial bereavement assessment in the social work evaluation dated 4/15/24 included the patients daughter who was present during the assessment. However, the social work evaluation also identified the patient was married and had 3 other children that would help care for her and her husband as needed. The agency failed to assess the initial bereavement needs of the additional identified individuals. P-2: This 88-year-old patient was admitted to this hospice facility on 1/6/25 with the terminal diagnosis of chronic obstructive pulmonary disease. During record review on 2/5/25, it was noted the initial bereavement assessment in the social work evaluation dated 1/8/25 included the patients daughter. However, the social work evaluation also stated the patients daughter and granddaughter shared medial and financial power of attorney for the patient. The agency failed to assess the initial bereavement needs of the patients granddaughter. Findings were reviewed with and acknowledged by the Director of Clinical Services and Finance (Director-B) during an interview on 2/6/25 at 9:00 AM. P-9: The referral was dated 8/7/2024. The Start of Care was dated 8/8/2024. The Plan of Care for the certification period 8/8/2024 to 11/5/2024 identified diagnoses of Nonrheumatic aortic valve disorder, Dependence on supplemental oxygen, Dyspnea, Chronic Kidney Disease, ST elevation (STEMI) myocardial infarction. The patient was receiving Skilled Nursing, and Medical Social Worker Services. Upon review of the record, it was noted that the Medical Social Worker failed to include all family members in the family contact document and the bereavement assessment. The patient had two living children, a daughter and son, however, the daughter was only family member whose contact information was included in the patient record. There was no further information, contact information or interviews with the patient's son by the MSW to determine if the patient's son was involved or had any bereavement needs. P-10: The referral was dated 10/25/2024. The Start of Care was dated 10/25/2024. The Plan of Care for the certification period 10/25/24 to 1/22/2025 identified diagnoses of Chronic Congestive Heart Failure, Coronary Artery Disease, Hypertension, Cardiomyopathy, Non-ST Elevation Myocardial Infarction, Hypothyroidism, Diabetes type 2, Chronic Kidney Disease. Upon review of the record, it was noted that the Medical Social Worker failed to document all Family Members in the bereavement assessment. The patient was residing with her daughter who was the primary caregiver for this patient. However, there were also 5 grandchildren living in the home. There was no evidence found in the record that the Social Worker had performed a bereavement risk assessment on the 5 children living with the patient. The Medical Social Worker failed to include all family members in the bereavement risk assessment. These findings were reviewed with and acknowledged by the Director of Clinical Services and Finance (Director-B) during an interview on 2/8/25 at 1:00 PM. P-3: The patient was admitted to Hospice services on 1/7/25 with a terminal diagnosis of Cardiomyopathy. The clinical record review conducted on 2/4/25 at 2:00 p.m. revealed a document titled "Family contact/HIPAA Approval" which documented the patient the patient had a spouse, 2 daughters and 1 son. The document was for all person's staff would communicate with regarding care. The Initial Bereavement Assessment dated 1/31/25 completed by the Medical Social Worker (MSW) only included the patient's wife. The assessment failed to include all parties (2 daughters and 1 son) who would be affected by the patient's death. These findings were reviewed with and acknowledged by the Educator/QAPI Coordinator during an interview on 2/7/25 at 9:15 a.m. P-4: The patient was admitted to Hospice services on 12/13/24 with a terminal diagnosis of Congestive Heart Failure. The clinical record was review on 2/5/25 at 8:20 a.m. and revealed the patient had a daughter. The Family Contact form documented that the patient had 3 sons and 1 sister. The Initial Bereavement Assessment dated 12/18/24, completed by the MSW only included one of the patient's sons. The assessment failed to include all parties who would be affected by the patient's death. These findings were reviewed with and acknowledged by the Educator/QAPI Coordinator during an interview on 2/7/25 at 9:35 a.m. P-17: This patient elected hospice on 6/19/24 with a terminal diagnosis of liver cancer with ascites (extra fluid in abdomen). During record review on 2/6/25, it was noted the hospice had a Family Contact HIPAA Approval form that listed the name of one son as primary care giver, then listed "others" which included two sons, a daughter-in-law, and a sister-in-law. The initial bereavement assessment conducted by the MSW on 6/24/24 included only the one son who was the primary caregiver. The initial bereavement assessment failed to include the other four family members. P-18: This patient elected hospice on 1/19/25 with a terminal diagnosis of leukemia. During record review on 2/6/25, it was noted that the patient's face sheet (information) listed one daughter as the emergency contact and another daughter as the primary care giver. The initial bereavement assessment conducted by the MSW on 1/24/25 included the daughter who was the primary caregiver. The initial bereavement assessment failed to include the other daughter identified as the emergency contact. P-3: The patient was admitted to Hospice services on 1/7/25 with a terminal diagnosis of Cardiomyopathy. The clinical record review conducted on 2/4/25 at 2:00 p.m. revealed a document titled "Family contact/HIPAA Approval" which documented the patient the patient had a spouse, 2 daughters and 1 son. The document was for all person's staff would communicate with regarding care. The Initial Bereavement Assessment dated 1/31/25 completed by the Medical Social Worker (MSW) only included the patient's wife. The assessment failed to include all parties (2 daughters and 1 son) who would be affected by the patient's death. These findings were reviewed with and acknowledged by the Educator/QAPI Coordinator during an interview on 2/7/25 at 9:15 a.m. P-4: The patient was admitted to Hospice services on 12/13/24 with a terminal diagnosis of Congestive Heart Failure. The clinical record was review on 2/5/25 at 8:20 a.m. and revealed the patient had a daughter. The Family Contact form documented that the patient had 3 sons and 1 sister. The Initial Bereavement Assessment dated 12/18/24, completed by the MSW only included one of the patient's sons. The assessment failed to include all parties who would be affected by the patient's death. These findings were reviewed with and acknowledged by the Educator/QAPI Coordinator during an interview on 2/7/25 at 9:35 a.m. P-9: The referral was dated 8/7/2024. The Start of Care was dated 8/8/2024. The Plan of Care for the certification period 8/8/2024 to 11/5/2024 identified diagnoses of Nonrheumatic aortic valve disorder, Dependence on supplemental oxygen, Dyspnea, Chronic Kidney Disease, ST elevation (STEMI) myocardial infarction. The patient was receiving Skilled Nursing, and Medical Social Worker Services. Upon review of the record, it was noted that the Medical Social Worker failed to include all family members in the family contact document and the bereavement assessment. The patient had two living children, a daughter and son, however, the daughter was only family member whose contact information was included in the patient record. There was no further information, contact information or interviews with the patient's son by the MSW to determine if the patient's son was involved or had any bereavement needs. P-10: The referral was dated 10/25/2024. The Start of Care was dated 10/25/2024. The Plan of Care for the certification period 10/25/24 to 1/22/2025 identified diagnoses of Chronic Congestive Heart Failure, Coronary Artery Disease, Hypertension, Cardiomyopathy, Non-ST Elevation Myocardial Infarction, Hypothyroidism, Diabetes type 2, Chronic Kidney Disease. Upon review of the record, it was noted that the Medical Social Worker failed to document all Family Members in the bereavement assessment. The patient was residing with her daughter who was the primary caregiver for this patient. However, there were also 5 grandchildren living in the home. There was no evidence found in the record that the Social Worker had performed a bereavement risk assessment on the 5 children living with the patient. The Medical Social Worker failed to include all family members in the bereavement risk assessment. These findings were reviewed with and acknowledged by the Director of Clinical Services and Finance (Director-B) during an interview on 2/8/25 at 1:00 PM. **Policy No. 1-021 titled ";Bereavement Assessment" (approved 8/31/2023) stated, ";The hospice bereavement plan of care will be developed based on an initial assessment of the patient and family/caregiver needs, during the course of care, and at the time of the patients death as part of the comprehensive assessment." P-1: This 83-year-old patient was admitted to this hospice agency on 4/13/24 with the terminal diagnosis of a malignant neoplasm of the left breast (breast cancer) and an unspecified intestinal obstruction. During record review on 2/5/25, it was noted the initial bereavement assessment in the social work evaluation dated 4/15/24 included the patients daughter who was present during the assessment. However, the social work evaluation also identified the patient was married and had 3 other children that would help care for her and her husband as needed. The agency failed to assess the initial bereavement needs of the additional identified individuals. P-2: This 88-year-old patient was admitted to this hospice facility on 1/6/25 with the terminal diagnosis of chronic obstructive pulmonary disease. During record review on 2/5/25, it was noted the initial bereavement assessment in the social work evaluation dated 1/8/25 included the patients daughter. However, the social work evaluation also stated the patients daughter and granddaughter shared medial and financial power of attorney for the patient. The agency failed to assess the initial bereavement needs of the patients granddaughter. Findings were reviewed with and acknowledged by the Director of Clinical Services and Finance (Director-B) during an interview on 2/6/25 at 9:00 AM. P-17: This patient elected hospice on 6/19/24 with a terminal diagnosis of liver cancer with ascites (extra fluid in abdomen). During record review on 2/6/25, it was noted the hospice had a Family Contact HIPAA Approval form that listed the name of one son as primary care giver, then listed "others" which included two sons, a daughter-in-law, and a sister-in-law. The initial bereavement assessment conducted by the MSW on 6/24/24 included only the one son who was the primary caregiver. The initial bereavement assessment failed to include the other four family members. P-18: This patient elected hospice on 1/19/25 with a terminal diagnosis of leukemia. During record review on 2/6/25, it was noted that the patient's face sheet (information) listed one daughter as the emergency contact and another daughter as the primary care giver. The initial bereavement assessment conducted by the MSW on 1/24/25 included the daughter who was the primary caregiver. The initial bereavement assessment failed to include the other daughter identified as the emergency contact.

Based on record review and interview, the agency failed to ensure the goals on the Plan of Care were measurable to determine progress towards meeting the goals implemented on the plan of care in 9 of 13 records (P-1, 2, 9, 10, 11, 12, 13, 15, 17) reviewed. Findings included: --- P-15: This patient elected hospice on 1/1/25 with terminal diagnoses of lung and brain cancer. During record review on 2/4/25, it was noted that the 1/1/25 plan of care failed to include measurable goals and outcomes pertinent to the needs of the patient or family. The plan includes a spiritual goal that states the patient/family will review life for meaning and acceptance. There was no indication as to how this goal would be measured by the spiritual care provider. A skilled nursing goal states the patient/caregiver will demonstrate techniques to promote wound healing. There was no indication how this goal would be measured by the nurse to ensure wound healing. P-17: This patient elected hospice on 6/19/24 with a terminal diagnosis of liver cancer with ascites (excess fluid in abdominal cavity). During record review on 2/6/25, it was noted that the 6/19/24 plan of care failed to include measurable goals and outcomes pertinent to the needs of the patient. A nursing goal states that the patient will be pain free or verbalize an acceptable pain level with current pain management regimen level. There was no indication what level of pain is acceptable to this patient. The findings were reviewed with and acknowledged by RN-K (quality assurance/educator) during an interview on 2/7/25 at 10:30 a.m. P-9: The referral was dated 8/7/2024. The Start of Care was dated 8/8/2024. The Plan of Care for the certification period 8/8/2024 to 11/5/2024 identified diagnoses of Nonrheumatic aortic valve disorder, Dependence on supplemental oxygen, Dyspnea, Chronic Kidney Disease, ST elevation (STEMI) myocardial infarction. The patient was receiving Skilled Nursing, and Medical Social Worker Services. Upon review of the Plan of Care, it was noted the goals were not objectively measurable to determine the patient's progress towards obtaining the goals. Examples included: "Patient/Caregiver administers medications appropriately with understanding of side effects and states implications and expected results; Maintenance of respiratory baselines as evidenced by breathing at optimal level within disease parameters; Patient will maintain optimum bowel functioning consistent with food intake and stage of disease process. These goals are not objectively measure to determine the patient's progress towards obtaining the goals. P-10: The referral was dated 10/25/2024. The Start of Care was dated 10/25/2024. The Plan of Care for the Certification Period 10/25/2024 to 1/22/2025 identified diagnoses of Chronic combined systolic and diastolic heart failure (CHF), Atherosclerotic heart disease, Hypertension, Non-ST elevation MI, ischemic cardiomyopathy, obesity, hypothyroidism, and Insulin Dependent Diabetes Mellites. The patient was receiving Skilled Nursing, Aide, Chaplain, and Medical Social Work Services. Upon review of the Plan of Care, it was noted the goals were not objectively measurable to determine the patient's progress towards goals. Examples included: "Patient's personal care needs will be met; Maintenance of respiratory baselines as evidenced by breathing at optimal level with disease parameters." These goals are not objectively measurable to determine the patient's progress towards achieving the goals. P-11: The referral was dated 1/5/24. The Start of Care was dated 1/7/2024. The Plan of Care for the certification period 1/7/24 to 1/27/2024 identified diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Unspecified Chronic Kidney Disease. The patient was receiving Skilled Nursing 1xday for 40 days with 5 PRN visits; Aide services 5x week for 4 weeks with 4 PRN visits; Medical Social Work 1 visit; and Chaplain services for 3 PRN (as needed) visits. Upon review of the Plan of Care, it was noted the goals were not objectively measurable to determine the patient's progress towards goals. Examples included: "Patient will be pain free or verbalize an acceptable pain level with current pain management regimen; Maintenance of respiratory baselines as evidenced by breathing at optimal level within disease, cough, and breathing patterns." These goals are not objectively measurable to determine the patient's progress towards achieving the goals. P-12: The referral was dated 12/16/2024. The Start of Care was dated 12/17/24. The Plan of Care for the certification period 12/17/24 to 3/16/2025. The Plan of Care identified diagnoses of Malignant neoplasm of lower-outer quadrant of right female breast, Vitamin D deficiency, Hypokalemia, Insomnia, Hypercholesterolemia, Congestive Heart Failure, and Vascular dementia without behavioral disturbance. The patient was receiving Skilled Nursing 1xweekx14 weeks with 5 prn visits; Aide services 2xweekx11 weeks with 5 prn visits; Medical Social Work services 1xmonthx4months with 4 prn visits; and Chaplain services for 4 prn visits. Upon review of the record, it was noted the goals were not objectively measurable to determine the patient's progress towards obtaining the goals. Examples included: Patient will maintain optimal coping through hospice care; Patient's personal care needs will be met; Pt/CG can describe/demonstrate measures to improve/maintain skin integrity; Patient/Caregiver/family will be able to identify potential complications, actions to take, and when to call Hospice. These goals are not objectively measurable to determine the patient's progress towards obtaining the goals. P-13: The Start of Care was dated 3/5/2024. The Plan of Care for the certification period 1/29/25 to 3/29/2025 identified diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Acute respiratory failure with hypoxia, and pneumonia. The patient was receiving Skilled Nursing and Hospice Aid services 1xweekx9 weeks + 5 PRN visits; Chaplain services 1-2 per month for 3 months with 3 PRN visits; Medical Social Work visits 1-2 visits per month for 2 months with 4 prn visits. Upon review of the record, it was noted the goals were not measurable to determine the patient's progress towards obtaining the goals. Examples included: "Patient/family will review life for meaning and joy; Patient and family spiritual needs met; Maintain clean, safe environment; Assist with necessary arrangements, planning; Maintain safe clean environment." These goals are not objectively measurable to determine the patient's progress towards attaining the goals. These findings were reviewed with and acknowledged by the Director of Clinical Services and Finance (Director-B) during an interview on 2/8/25 at 1:00 PM. **Policy No. 3-002 titled ";Patient Focused Performance Improvement" (revised 4/2021) stated, ";1. At the time of admission and on and ongoing basis, an individualized plan of care/service including specific and measurable goals will be developed for each patient." P-1: This 83-year-old patient was admitted to this hospice agency on 4/13/24 with the terminal diagnosis of a malignant neoplasm of the left breast (breast cancer) and an unspecified intestinal obstruction. During record review on 2/5/25, it was noted the goals on the plan of care dated 4/13/24 were not objectively measurable to allow patient progress to be tracked and the need for revisions in treatment to be identified. For example, a skilled nursing goal stated, ";Maintenance of respiratory baselines as evidenced by breathing at optimal level within disease parameters." [sic] A social work goal stated, ";Continuity of care will be maintained as appropriate to patient/primary caregiver needs." P-2: This 88-year-old patient was admitted to this hospice facility on 1/6/25 with the terminal diagnosis of chronic obstructive pulmonary disease. During record review on 2/5/25, it was noted the goals on the plan of care dated 1/6/25 were not objectively measurable to allow patient progress to be tracked and the need for revisions in treatment to be identified. For example, a skilled nursing goal stated, ";CG (caregiver) can maintain usual bowel patterns." A hospice aide goal stated, ";CG can perform ADL with optimal ability." Findings were reviewed with and acknowledged by the Director of Clinical Services and Finance (Director-B) during an interview on 2/6/25 at 9:00 AM.

Based on record review and interview, the Hospice failed to maintain an effective system of communication and an ongoing sharing of information between the Physician and ordered disciplines in 1 (P-3) record in which the patient experienced a significant change in condition, from a total of 19 sampled patients reviewed, resulting in lack of coordinated care, the potential for unidentified/untreated health concerns and unmet patient care needs. Findings include: --- P-3: The patient was admitted to hospice on 1/7/25 with a terminal diagnosis of Cardiomyopathy, and additional diagnoses that included Parkinson's Dementia and Hypertension. During the record review on 2/4/25 at 2:00 p.m., it was noted that the plan of care ordered the patient to receive Skilled Nursing (SN) services at a frequency of 2x/wk. x 13 wks. and 5 prn (as needed) visits. A "Communication Note" dated 2/1/25 at 1:09 a.m., documented by the Triage Nurse read, "Received call at 02/01/2025 01:01 form [sic] daughter reporting ingoing [sic] anxiousness and delirium. Caller reports patient had HS (nighttime) routine medications and Seroquel tonight, caller reports patient has not slept the last 3 nights. Caller states patient is not speaking of sound mind, is restless and has not has [sic] sleep in several days. Caller states "he may have a fever". Writer reviews chart and recommends use of PRN Haldol, caller refuses to administer stating she gave it 3 nights ago and it was not effective. Caller requesting nurse visit for evaluation. 24/7 availability reinforced. Writer placed on DL (Dispatch Log) for dispatch." At the time of this review, there was no documented evidence that the SN had performed a follow-up visit to assess the health needs of the patient. Additionally, there was no documented evidence that the Physician or Interdisciplinary Team had been made aware of the patient's change in condition. These findings were reviewed with the Educator/QAPI Coordinator during an interview on 2/7/25 at 9:15 a.m. who reported, "Let me check the Dispatch Log; I don't have an explanation as to why there was no follow-up. That's a problem."

Based on record review and interview, it was determined the hospice failed to ensure its Quality Assessment Performance Improvement (QAPI) program included all patient services that impact patient/family care as part of the QAPI program. Findings include: --- On 2/7/25 at 10:06 a.m., during an interview with the QAPI Coordinator, a request was made to review the QAPI data for calendar years 2023 and 2024. Upon review, there was no documented evidence the 2023/2024 QAPI reports included all patient services and how they impact patient/family care as part of the QAPI program. These findings were reviewed with and acknowledged by the QAPI Coordinator at the time of discovery.

Based on documents reviewed and interview, the hospice failed to ensure the QAPI performance improvement activities focus on high risk, high volume, or problem-prone areas. Findings include: --- On 2/7/25 at 10:06 a.m., during an interview with the QAPI Coordinator, a request was made to review the QAPI data for calendar years 2023 and 2024. Upon review, there was no documented evidence the 2023/2024 QAPI reports focused on high volume problem prone areas. During a review of the agency's incident reports for calendar years 2023/2024, it was noted that there were a significant number of reported and unwitnessed falls. However, the agency focused on Performance Improvement topics such as "Improving GSS (grief support) survey scores, Compliance Committee and Orientation Program." These were the chosen projects for both calendar years 2023 and 2024. There was no documented evidence that the Performance Improvement Projects included all patient services and how they impacted patient/family care as part of the QAPI program. These findings were reviewed with and acknowledged by the QAPI Coordinator at the time of discovery.

Based on record review and interview, the agency failed to ensure its Performance Improvement Projects tracked adverse patient events, analyzed causative factors and implemented preventive measures to prevent reoccurrence. Findings include: --- On 2/7/25 at 10:06 a.m., during an interview with the QAPI Coordinator, a request was made to review the QAPI data for calendar years 2023 and 2024. Upon review, there was no documented evidence the 2023/2024 QAPI reports tracked adverse patient events, analyzed causative factors and developed improvements. During a review of the agency's incident reports for calendar years 2023/2024, it was noted that there were a significant number of reported and unwitnessed falls. However, the agency's Performance Improvement Projects consisted of topics such as "Improving GSS (grief support) survey scores, Compliance Committee and Orientation Program." These were the chosen projects for both calendar years 2023 and 2024. There was no documented evidence that the Performance Improvement Projects tracked adverse events, analyzed causative factors and developed preventative measures to prevent reoccurrence. These findings were reviewed with and acknowledged by the QAPI Coordinator at the time of discovery.

Based on record review and interview, the governing body failed to ensure responsibility and annually evaluate the hospice's quality assurance and performance improvement program in 2024, resulting in a lack of oversight for the hospice quality improvement program. Findings include: --- The monthly Board of Director Meeting minutes for 2024 were reviewed on 2/6/25 at 10:45 a.m. During review of the meeting minutes, it was noted that there was no documentation to indicate the Board of Directors had discussed or reviewed matters related to the hospice's quality assurance and performance improvement program. The findings were reviewed with and acknowledged by Admin-A (executive director) during an interview on 2/7/25 at 1:30 p.m.

Based on record review and interview, it was determined that the Agency failed to coordinate an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of the Hospice's Quality Assessment Performance Improvement program, resulting in the potential for increased, untreated infections among the Agency's active patients, and staff population. Findings include: --- On 2/7/25 at 10:06 a.m., during an interview with the QAPI Coordinator, a request was made to review the QAPI data for calendar years 2023 and 2024. Upon review, there was no documented evidence the 2023/2024 QAPI data included any discussions on infection Control. Upon review of the Governing board meeting minutes for calendar year 2024, there was no inclusion of the topic of infection control. Additionally, there were no projects that addressed the agency's infections as identified in the surveillance report provided for review. The agency failed to ensure its infection control program was included in the QAPI program. These findings were reviewed with and acknowledged by the QAPI Coordinator at the time of discovery.

Based on record review and interview, it was determined that the hospice failed to ensure follow-up nursing assessments were conducted to ensure the needs of the patient were met for 1 (P-3) patient who experienced a significant change in condition, from a total of 19 sampled records reviewed, resulting in the potential for unidentified/untreated health concerns and progression towards end of life. Findings include: --- P-3: The patient was admitted to hospice on 1/7/25 with a terminal diagnosis of Cardiomyopathy, and additional diagnoses that included Parkinson's Dementia and Hypertension. During the record review on 2/4/25 at 2:00 p.m., it was noted that the plan of care ordered the patient to receive Skilled Nursing (SN) services at a frequency of 2x/wk. x 13 wks. and 5 prn (as needed) visits. A "Communication Note" dated 2/1/25 at 1:09 a.m., documented by the Triage Nurse read, "Received call at 02/01/2025 01:01 form [sic] daughter reporting ingoing [sic] anxiousness and delirium. Caller reports patient had HS (nighttime) routine medications and Seroquel tonight, caller reports patient has not slept the last 3 nights. Caller states patient is not speaking of sound mind, is restless and has not has [sic] sleep in several days. Caller states "he may have a fever". Writer reviews chart and recommends use of PRN Haldol, caller refuses to administer stating she gave it 3 nights ago and it was not effective. Caller requesting nurse visit for evaluation. 24/7 availability reinforced. Writer placed on DL (Dispatch Log) for dispatch." At the time of this review, the SN had not performed a follow-up visit to assess the urgent needs of the patient. Additionally, there was no further documentation of the status of the patient. These findings were reviewed with the Educator/QAPI Coordinator during an interview on 2/7/25 at 9:15 a.m. who reported, "Let me check the Dispatch Log; I don't have an explanation as to why there was no follow-up. That's a problem."

Based on the record review and interview, it was determined the Hospice failed to make bereavement/grief support services available to the bereaved family member up to 1 year following the death of the patient in 3 (P-6, P-7, P-8) of 3 bereavement records, and failed to complete a bereavement plan of care that listed the bereaved family members, resulting in the potential for ineffective coping/grieving, lack of grief support and unmet bereavement needs. Findings include: --- P-6: The patient was admitted to Hospice on 12/27/24 with a terminal diagnosis of Malignant Neoplasm Right Lung and Brain Cancer. During the record review on 2/6/25 at 9:30 a.m., it was noted that the patient passed away on 1/9/25. The Initial Bereavement Risk Assessment dated 12/31/24, completed by the Medical social Worker (MSW) identified the patient's wife as the bereaved. A Celebration of Life document stated the patient was survived by his wife, 2 sisters, 2 brothers, 2 sons and a daughter. The section of the "Grief & Loss Risk Assessment" dated 1/15/25, completed by the Bereavement Coordinator, documented, "Primary Caregiver, Family and Significant Others Involved in Care:" only listed the patient's wife. Upon further review, the Bereavement POC was void of persons who would be affected by the patients death and receive grief support services. Additionally, there were no frequencies in which contact would be made or when services would be provided. The Hospice failed to make bereavement/grief support services available to the bereaved family members. These findings were reviewed with and acknowledged by the Educator/QAPI Coordinator during an interview on 2/7/25 at 9:50 a.m. P-7: The patient was admitted to Hospice on 12/8/23 with a terminal diagnosis of Left Ventricular Failure. During the record review on 2/6/25 at 10:50 a.m., it was noted that the patient passed away on 12/25/23. The Initial Bereavement Risk Assessment dated 12/11/23, completed by the MSW, only identified the patient's wife as the bereaved. A Celebration of Life document stated the patient was survived by his wife, son and grandson and read, "The patient loved his grandson very much..." The document further stated that the patient was also survived by 5 siblings. The Grief & Loss Risk Assessment dated 12/27/23, completed by the Bereavement Coordinator, only listed the patient's wife as the person to receive grief support. Upon further review, the Bereavement POC revealed that none of the above-mentioned family members were included in the POC, and there were no frequencies in which contact would be made or when services would be provided. The Hospice failed to make bereavement/grief support services available to the bereaved family members. These findings were reviewed with and acknowledged by the Educator/QAPI Coordinator during an interview on 2/7/25 at 10:00 a.m. P-8: The patient was admitted to Hospice on 8/5/24 with a terminal diagnosis of ST Elevation Myocardial Infarction. During the record review on 2/6/25 at 12:40 p.m., it was noted that the patient passed away on 8/17/24. The Initial Bereavement Risk Assessment dated 8/6/24, completed by the MSW, only identified the patient's wife as the bereaved. A Celebration of Life document stated the patient was survived by his wife, 2 sons and 4 grandchildren. The Grief & Loss Risk Assessment dated 8/21/24, completed by the Bereavement Coordinator, only listed the patient's wife as the person to receive grief support. Upon further review, the Bereavement POC revealed that none of the bereaved family members were listed and there were no frequencies in which contact would be made or when services would be provided. The Hospice failed to make bereavement/grief support services available to the bereaved family members. These findings were reviewed with and acknowledged by the Educator/QAPI Coordinator during an interview on 2/7/25 at 10:05 a.m. BC #1 at the time of discovery.

Based on record review and interview the hospice failed to ensure hospice aides received at least 12 hours of in-service training annually for 3 (Aide-E, Aide-F, and Aide-G) of 3 aide personnel files reviewed of aides employed for more than 12 months, resulting in a lack of educational development and training opportunities for these 3 aides. Findings include: --- The personnel files for three aides were reviewed on 2/6/25 and the following was noted: Aide-E: Date of hire 5/8/23. No in-service education for 2023 was provided for review. The 2024 in-service education totaled 11.45 hours. Aide-F: Date of hire 9/23/22. The 2023 in-service education totaled 9.2 hours. The 2024 in-service education totaled 10 hours. Aide-G: Date of hire 8/1/22. No in-service education for 2023 was provided for review. The 2024 in-service education totaled 11 hours. The hospice failed to follow its own policy titled, Training/Inservice Education No.1-033 (revised April 2021), which states aides must receive at least 12 hours of in-service training per calendar year. The findings were reviewed with and acknowledged by Manager-H (human resources) during an interview on 2/6/25 at 11:35 p.m.

Based on record review and interview, the hospice failed to ensure the registered nurse prepared written patient specific care instructions that included safety precautions and the frequency in which ordered tasks were to be performed for 7 (P-1, P-2, P-3, P-4, P-15, P-16, P-19) of 8 records in which aide services were provided, from a total of 19 sampled records reviewed, resulting in the potential for injury and overlooked care needs. Findings include: --- P-15: This patient elected hospice on 1/1/25 with terminal diagnoses of lung and brain cancer. During record review on 2/4/25, it was noted that the aide was ordered to provide services 3 times a week for 14 weeks. The aide care plan instructed the aide to provide assistance with personal care/hygiene and activities of daily living. The aide care plan failed to indicate the frequency of the assistance with personal care/hygiene and activities of daily living. It was unclear if the aide was to provide bathing and all care/services 3 times per week, twice a week, or once a week. The hospice plan of care included the following safety measures: safe transfers, skin breakdown prevention, transfer precautions, and ambulation precautions. The aide care plan failed to include these safety measures to alert the aide to the specific care required for this patient. P-16: This patient elected hospice on 1/31/25 with terminal diagnoses of congestive heart failure and diabetes. During record review on 2/5/25, it was noted that the aide was ordered to provide services 3 times a week for 9 weeks. The aide care plan instructed the aide to provide assistance with personal care/hygiene and activities of daily living. The aide care plan failed to indicate the frequency of the assistance with personal care/hygiene and activities of daily living. It was unclear if the aide was to provide bathing and shampoo hair 3 times per week, twice a week, or once a week. P-19: This patient elected hospice on 12/27/24 with a terminal diagnosis of encephalopathy (a change in brain function). During record review on 2/6/25, it was noted that the aide was ordered to provide services 2 times a week for 1 week and then 3 times a week for 12 weeks. The aide care plan instructed the aide to provide assistance with personal care/hygiene and activities of daily living. The aide care plan failed to indicate the frequency of the assistance with personal care/hygiene and activities of daily living. It was unclear if the aide was to provide bathing and all care/services 3 times per week, twice a week, or once a week. The hospice plan of care included the following safety measures: fall precautions and seizure precautions. The aide care plan failed to include these safety measures to alert the aide to the specific care required for this patient. P-3: The patient was admitted to hospice on 1/7/25 with a terminal diagnosis of Cardiomyopathy. During the clinical record review on 2/4/25 at 2:00 p.m., it was noted that the patient was ordered to receive Hospice Aide services at a frequency of 1x/wk. x 12 wks. and 5 prn (as needed) visits. The Hospice plan of care revealed the patient had dyspnea (shortness of breath) with minimal exertion and had fall/ambulation precautions. The Aide Care Plan failed to include any safety precautions. Additionally, there was no specified frequency in which the ordered tasks were to be performed. These findings were reviewed with and acknowledged by the Educator/QAPI Coordinator during an interview on 2/7/25 at 9:15 a.m. P-4: The patient was admitted to hospice on 12/13/24 with a terminal diagnosis of Congestive Heart Failure. During the record review on 2/5/25 at 8:20 a.m., it was noted that the patient was ordered to receive Hospice Aide services at a frequency of 3x/wk. x 13 wks. and 5 prn visits. The Hospice plan of care revealed the patient had dyspnea with minimal exertion, ambulation/fall precautions and received oxygen. Upon review, the Aide Care Plan was void of any of the above-mentioned safety precautions. Additionally, there was no specified frequency in which the ordered tasks were to be performed. These findings were reviewed with and acknowledged by the Educator/QAPI Coordinator during an interview on 2/7/25 at 9:35 a.m. P-1: This 83-year-old patient was admitted to this hospice agency on 4/13/24 with the terminal diagnosis of a malignant neoplasm of the left breast (breast cancer) and an unspecified intestinal obstruction. Hospice aide services were ordered for 2-3 times per week for 13 weeks with 5 PRN (as needed) visits. The hospice plan of care dated 4/13/24 indicated the patient had fall precautions and standard precautions. The aide care plan failed to include these safety precautions. Additionally, the aide care plan failed to include the frequency for each intervention/task on the care plan to be performed by the aide. P-2: This 88-year-old patient was admitted to this hospice facility on 1/6/25 with the terminal diagnosis of chronic obstructive pulmonary disease. Hospice aide services were ordered for 3 times a week for 13 weeks. The hospice plan of care dated and skilled nursing evaluation (both dated 1/6/25) indicated the patient had dyspnea with exertion and was on up to 6 liters of oxygen. The aide care plan failed to include safety and oxygen precautions. Additionally, the aide care plan failed to include the frequency for each intervention/task to be performed by the aide. During an interview with hospice aide (Aide-J) on 2/5/25 at 1:15 PM, Aide-J was asked how she knows how often to perform the interventions in the aide care plan. Aide-J stated it ";is assumed" it is every visit unless otherwise specified. During an interview with the Director of Clinical Services and Finance (Director-B) on 2/6/25 at 9:00 AM, Director-B agreed with the statement above, however, he agreed how this could be unclear and should be documented better to avoid confusion. Director-B acknowledged the findings.

Based on record review and interview, the hospice failed to ensure the aide provided care in accordance with the plan of care in 1 (P-1) of 8 records reviewed with hospice aide services, resulting in the potential for poor patient outcomes and unmet care needs. Findings include: --- P-1: This 83-year-old patient was admitted to this hospice agency on 4/13/24 with the terminal diagnosis of a malignant neoplasm of the left breast (breast cancer) and an unspecified intestinal obstruction. During record review on 2/5/25, it was noted the aide care plan dated 4/13/24 stated, ";3. Elimination – Document bowel movements (Varianced)." [sic] During review of 10 hospice aide visits between 4/15/24 and 5/17/24, it was determined 10 of 10 aide visits stated ";Unable to Document: Not applicable this visit" or ";Done" after this intervention, however, failed to include a date of when a bowel movement occurred. Findings were reviewed with and acknowledged by the Director of Clinical Services and Finance (Director-B) during an interview on 2/6/25 at 9:00 AM.

Based on record review and interview, the Hospice failed to ensure a Discharge Summary was completed that detailed the course of care provided, including symptom and pain management, responses to treatment, Physician's orders and the patient's health status at the time of discharge for 1 P-4) of 2 patients who were discharged to the community or revoked Hospice services, from a total of 19 sampled records reviewed, resulting in the potential for unmet care needs and interruption in post-discharge continuity of care. Findings include: --- Policy: Discharge Summary 1-026, 82023 stated, "All patients discharged from a service and from hospice will have a discharge summary completed and filed in the clinical record; A copy of the discharge summary will be provided to the patient's attending physician." P-4: The patient was admitted to Hospice on 12/13/24 with a terminal diagnosis of Congestive Heart Failure. During the clinical record review on 2/5/25 at 8:20 a.m., it was noted that the plan of care ordered Skilled Nursing (SN), Spiritual Care (SC), Medical social Work (MSW) and Hospice Aide services to be provided. A document titled "Live Discharge Notification" documented, "I hereby give notice on 12/21/24 that I no longer wish to receive hospice services..., I am choosing revocation of hospice services for the following reason: Seeking curative treatment." There was no summary of care available for review. The Hospice failed to complete a Discharge Summary that detailed the course of care provided and the patient's health status at the time of discharge/revocation. Further, there was no documented evidence that the Physician was provided a copy of the summary as per this requirement. These findings were reviewed with the Educator/QAPI Coordinator during an interview on 2/7/25 at 9:35 a.m.

Based on observation, record review, and interview, the agency failed to ensure coordination of hospice care with the skilled nursing facility in 1 (P-2) of 5 records reviewed of patients residing in skilled nursing facilities, resulting in the potential for unmet care needs due to a lack of communication between the agency and the facility. Findings include: --- **Policy No. 1-027 titled ";Missed Visits" (approved 8/31/2023) stated, ";B. Document in the patients medical record the following information:....6. Other person(s) that were notified of the missed visit." P-2: This 88-year-old patient was admitted to this hospice facility on 1/6/25 with the terminal diagnosis of chronic obstructive pulmonary disease. During a joint home visit with the hospice aide (Aide-J) on 2/5/25 at 1:00 PM, the patient declined the hospice aide visit because she had already gotten dressed for the day and did not want to get undressed again to shower. Aide-J was observed verbally telling a staff member in the hall of the facility that the patient declined, and the aide would be back later in the week. After the attempted visit, Aide-J was asked how missed visits are typically handled for patients living in a skilled facility. Aide-J stated she typically lets a staff member at the facility know, however, admitted that the communication is not documented in the patient's record. Additionally, it was noted the patient had missed visits on 1/13/25, 1/20/25, and 1/27/25 per patient request. The reasons for the missed visits were documented, however, there was no evidence it was communicated with the staff at the nursing facility. Findings were reviewed with and acknowledged by the Director of Clinical Services and Finance (Director-B) during an interview on 2/6/25 at 9:00 AM.

Based on record review and interview, the Hospice failed to ensure that each patient's record included the rationale for discharge in 1 (P-1) of 2 inactive records reviewed, from a total sample of 7 records reviewed, resulting in an incomplete clinical picture of the patient's status at time of discharge. Findings include: --- P-1: The patient was admitted to the Hospice agency on 5/8/23, with a terminal diagnosis of CHF (congestive heart failure). During the investigation concerning intake #99049 on 6/29/23, record review noted the patient had been discharged from the Hospice agency on 4/20/23. Skilled Nursing (SN) documented the reason as "no longer meeting eligibility criteria." However, further record review noted that P-1 had been admitted to the hospital three days later (4/23/23) for chronic hypoxemic respiratory failure. According to hospital records on 4/23/23, P-1's condition was exacerbated (made worse) with "3 Fentanyl patches on and had taken 20 mg. of Norco (narcotic pain reliever) earlier in day." Additional record review was performed to ascertain the decision-making processes of why the Hospice agency's Medical Director (MD#1) had discharged the patient considering the above findings. No documentation was found which detailed why P-1 was found to be ineligible. Subsequently on 6/29/23 at 1:10 PM., a request was made to the Executive Director (ED#1) and Director of Clinical Services (DCS#1) for any documentation which detailed the reasons why the patient was "no longer meeting eligibility criteria." At 1:40 PM., DCS#1 stated he spoke to MD#1, who was under the impression no documentation was needed whenever a patient was deemed to no longer meet eligibility criteria. During an interview at 1:55 PM., both ED#1 and DCS#1 acknowledged this did not meet the Hospice's expectations and that documentation which detailed the rationale behind P-1's discharge should have been included in the clinical record. The Hospice agency failed to ensure the clinical record incorporated the reasoning behind P-1's discharge, particularly when a poor clinical outcome was evidenced 3 days later.

Based on record review and interview, it was determined the hospice failed to abide to agency patient rights policies to ensure the patient received effective pain management from the hospice as related to the terminal illness for 1 of 3 records reviewed, (MR #1), resulting in the patient dying without comfort and effective pain relief. Findings included: Agency Policy as documented in the "Information for Patient and Family Admission Booklet": "Patient, Family Rights and Responsibilities, and Grievance Procedures." The Policy States, You have the right to receive services appropriate to your needs and expect the Agency to provide safe, professional care at the level of intensity needed; To have access to necessary professional services 24 hours a day, 7 days a week; to receive care/services from staff who are trained and qualified to carry out the duties for which they are assigned; To adequate and appropriate pain and symptom management as a basic and essential element of your medical treatment; To have your reports of pain believed and responded to quickly by staff trained and qualified in pain management; and to receive verbal and/or written instruction regarding pain relief measures, including possible side effects." {sic} MR#1: The patient was admitted to the hospice on 12/26/2019 with a terminal diagnosis of Diffuse Large B-cell Lymphoma that had spread to his stomach, spleen, pancreas, adrenal glands, colon and diaphragm, Atherosclerotic heart disease of native coronary artery without angina pectoris, Essential hypertension, and Anxiety disorder. The following information was obtained during an interview with the patient's wife on 3/22/2022, at 4:00 pm: The wife stated, "My daughter was alone with my husband on 2/4/2020, and he was screaming in pain. The pain medication was ordered to be given rectally. She didn't know how to give the pain medication rectally and felt uncomfortable in administering medicine rectally to her own dad. My daughter called the night nurse three times asking him to come and give the suppository, and he said "no, I'm not coming" all three times. My husband died screaming, crying, and yelling in pain, which was horrifying and traumatic for my daughter to witness as her father died in such a manner. My daughter is devastated and still has nightmares regarding the painful and unmerciful death of her father, a memory, I'm sure will last the rest of her life. When the night nurse finally did come to the house to pronounce my husband's death, he asked if we (Wings of Hope) had kept him comfortable? This was an uncanny comment to make considering the patient (my husband) died with excruciating pain due to the refusal of the nurse to make the visit. When I lodged a complaint to the agency, the Administrator (ADM-B) asked "who told your daughter that the nurse would come out to give the suppository if she couldn't do it ...that was where the breakdown was." The complainant stated, "that didn't matter if someone had told my daughter that or not. When she called 3 times, the nurse should have got his butt out there {sic}." The agency failed to ensure the Registered Nurse abided by the Agency's policies, procedures, and patient's rights. The result was the patient and family were denied the right to comfort care, quality of life, peace and support at the end of life for their loved one (the very premise and purpose of Hospice Care); and mental trauma for the patient's daughter who witness her father crying, screaming, and yelling during a painful death.

Based on record review and interview, the Agency failed to develop an emergency preparedness plan that was reviewed and updated at least every 2 years, and included guidance for the Covid-19 pandemic, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster. This deficient practice could affect the health and safety of all staff employed by this agency, regularly utilized contracted staff and all 37 patients currently serviced by this Agency in the event of an emergency or disaster (E0004); failed to ensure an emergency plan existed that was based on a documented facility and community-based risk assessment from an all-hazards approach, including strategies for the Covid-19 global pandemic, resulting in the potential for lack of preparedness and poor patient and staff outcomes, in the event of an actual emergency (E0006); failed to develop an Emergency Preparedness policy/Plan, that included the use of volunteers, as appropriate, and/or other emergency staffing strategies to address surge needs during the COVID-19 crisis, resulting in the potential for the interruption in needed care and services for staff and all 37 patients currently serviced by this agency (E0024); failed to develop and maintain a communication plan for emergency preparedness that had been updated every 2 years, and had strategies in place that included the global Covid-19 pandemic, resulting in the inability to effectively communicate with staff and officials in the event of an actual disaster, and the potential for uncoordinated care for all 37 patients currently serviced by this Agency in the event of a facility emergency or disaster (E0029); failed to develop and maintain an emergency preparedness communication plan that included contact information for all current staff, patient's physicians, any contract employees and volunteers, as appropriate, which had the potential to negatively affect the health and safety of the 37 patients currently serviced by this agency, resulting in the lack of effective communication in the event of an actual emergency (E0030); failed to provide initial and ongoing training in emergency preparedness policies and procedures to all new and existing staff, including contract employees and volunteers, and failed to maintain documentation of training's, resulting in the potential for inappropriate, unprepared responses to emergencies and interruption in the provision of needed patient care and services. This deficient practice could potentially negatively affect all staff and all 37 patients currently serviced by this Agency (E0037); and, failed to provide documentation for the required community/facility based full-scale exercises or an actual event that would qualify as a test of the emergency plan, resulting in staff being ill-prepared in the event of an actual emergency. This deficient practice could negatively affect all 37 patients currently serviced by this Agency (E0039). The cumulative effect of these systemic problems resulted in the agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation 42 CFR §418.113 Emergency Preparedness.

Based on record review and interview, the Agency failed to develop an emergency preparedness plan that was reviewed and updated at least every 2 years, and included guidance for the Covid-19 pandemic, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster. This deficient practice could affect the health and safety of all staff employed by this agency, regularly utilized contracted staff and all 37 patients currently serviced by this Agency in the event of an emergency or disaster. Findings include: On 2/8/22 at 11:15 a.m., the agency's Emergency Preparedness documents were reviewed with the Administrator (Adm #1). Upon review of the documents, it was noted that the agency's plan was dated 11/14/17. Additionally, there was no language that addressed the Covid-19 global pandemic. There was no documented evidence that showed the agency had developed an Emergency Preparedness plan that had been reviewed/updated and included all the required elements in accordance with the requirements of this section. These findings were reviewed with and acknowledged by Adm #1 at the time of discovery who reported, "I guess we just fell short on this one."

Based on record review and interview, the Agency failed to ensure an emergency plan existed that was based on a documented facility and community-based risk assessment from an all-hazards approach, including strategies for the Covid-19 global pandemic, resulting in the potential for lack of preparedness and poor patient and staff outcomes, in the event of an actual emergency. Findings include: On 2/8/22 at 11:15 a.m., the agency's Emergency Preparedness documents were reviewed. The Risk Assessment was dated 11/14/17. There was no documented evidence that the agency's Risk Assessment had been reviewed/updated and included consequences of power failures, the identification of Covid-19, natural disasters or any other situation that would prevent the ability to provide care and services. Further, the agency's Emergency Preparedness Plan failed to include strategies to address the Covid-19 global pandemic. These findings were reviewed with and confirmed by the Administrator (Adm #1) at the time of discovery and again on 2/9/22.

Based on record review and interview, the Agency failed to develop an Emergency Preparedness policy/Plan, that had been updated/reviewed at least every 2 years, included the use of volunteers, as appropriate, and/or other emergency staffing strategies to address surge needs during the identified risks that also included the COVID-19 crisis, resulting in the potential for the interruption in needed care and services for staff and all 37 patients currently serviced by this agency. Findings included: A review the agency's Emergency Preparedness Plan was conducted on 2/8/22 at 11:15 a.m. During the review, it was noted that the agency's plan was dated 11/14/17. Further, there was no clear delineation of duties and no specific language that included a process for the integration or use of volunteers, as appropriate, or other staffing strategies with local, regional, State, and Federal officials to address surge needs during an emergency and the COVID-19 crisis. These findings were reviewed with and acknowledged by the Administrator (Adm #1) at the time of discovery.

Based on record review and interview, the Agency failed to develop and maintain a communication plan for emergency preparedness that had been updated every 2 years, and had strategies in place that included the global Covid-19 pandemic, resulting in the inability to effectively communicate with staff and officials in the event of an actual disaster, and the potential for uncoordinated care for all 37 patients currently serviced by this Agency in the event of a facility emergency or disaster. Findings include: On 2/8/22 at 11:15 a.m., the agency's Emergency Preparedness documentation was reviewed. During the review, it was noted that the plan was dated 11/14/17. The agency's Communication Plan had not been updated every 2 years as per this requirement. Further, there was no clear delineation of duties. A document titled, "Organization Chart for Disaster Response Team" made no mention of the person or persons who would be responsible for carrying out the assigned tasks. During the survey, it was noted that the agency also provided care for patients who resided in a long term facility. There was no guidance on how communication would take place with the patients or staff in that facility. These findings were reviewed with and acknowledged by the Administrator (Adm #1) at the time of discovery.

Based on record review and interview, it was determined that the facility failed to develop and maintain an emergency preparedness communication plan that included contact information for all current staff, patient's physicians, any contract employees and volunteers, as appropriate, which had the potential to negatively affect the health and safety of the 37 patients currently serviced by this agency, resulting in the lack of effective communication in the event of an actual emergency. Findings include: On 2/8/22 at 11:15 a.m., during a review of the agency's emergency preparedness documents, it was noted that there was no contact information for all current hospice staff, patient's physicians, contract employees or volunteers as appropriate. These findings were reviewed with and confirmed by the Administrator (Adm #1) at the time of discovery.

Based on record review and interview, the Agency failed to provide initial and ongoing training in emergency preparedness policies and procedures to all new and existing staff, including contract employees and volunteers, and failed to maintain documentation of training's, resulting in the potential for inappropriate, unprepared responses to emergencies and interruption in the provision of needed patient care and services. This deficient practice could potentially negatively affect all staff and all 37 patients currently serviced by this Agency. Findings include: On 2/8/22 at 11:15 a.m., the agency's Emergency Preparedness documentation was reviewed with the Administrator (Adm #1). A request was made to review the staff's initial training in emergency preparedness that included the topic of Covid-19, as well as the every 2 year training. There was no documented evidence that all Agency staff had received initial or ongoing training in emergency preparedness. During an interview, the Bereavement Coordinator (BC #1) provided a list of signatures. It was reported that this was an emergency preparedness drill sign in sheet. There was no content available for review. These findings were reviewed with and acknowledged by Adm #1 at the time of discovery.

Based on record review and interview, the Agency failed to provide documentation for the required community/facility based full-scale exercises and tabletop exercises, and failed to provide documentation of an actual event that would qualify as a test of the emergency plan, resulting in staff being unprepared in the event of an actual emergency. This deficient practice could negatively affect all 37 patients serviced by this Agency. Findings include: During a review of the agency's "Emergency/Disaster Preparedness Plan" on 2/8/22 at 11:15 a.m., it was noted that there was no documented evidence that the agency had conducted any training or exercises to test the agencies emergency plan. Further, there was no documentation of an actual event that would qualify as an emergency, no community based full-scale exercise, no second full-scale exercise or a table-top exercise as per this requirement. The Agency failed to provide documented evidence that the required trainings had been conducted. A document titled "Community Drill - Table Top" dated 3/28/18 documented that the Administrator (Adm #1) "attended this drill..." There was no documented evidence that all staff received or participated in any training in Emergency Preparedness. The above findings were reviewed with and confirmed by Adm #1 at the time of discovery.

Based on record review and interview, the hospice failed to ensure the comprehensive assessment included a complete drug profile to identify effectiveness of drug therapy, drug side effects, actual or potential drug interactions, and duplicate drug therapy for 11 of 13 records reviewed. (MR's #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13) resulting in the potential for harm to the patient from adverse medication interactions. Findings included: MR#1: The Start of Care was dated 1/28/22. The patient was admitted with diagnoses of Renal Failure, Chronic Kidney Disease stage 4, (CKD4), Congestive Heart Failure (CHF), Hypertension (HTN), and Peripheral Vascular Disease (PVD). Upon review of the patient's record, a review of the patient's current medications via drugs.com, revealed one (1) major drug interactions as follows: A major drug interaction was identified with the concurrent use of Hydrocodone and Gabapentin. The use of these two drugs together can lead to serious side effects including respiratory distress, coma, and even death. During the review of the patient's record, there was no communication found within the patient's record, or within documentation of the IDT (Interdisciplinary Team) meetings that a major drug interaction was identified, communicated, or resolved. MR#2: The Start of Care was dated 1/23/2022. The patient was admitted with diagnoses of Malignant neoplasm of Ovary, and Covid-19, Hypertension, Diabetes Type 2 and Pulmonary Fibrosis. Upon review of the patient's prescribed medications via drugs.com, the following 3 major interactions were identified: (1) The Concurrent use of Haloperidol and Benadryl can lead to respiratory distress, coma, and even death. (2) The use of Haloperidol together with Compazine can increase the risk of an irregular heart rhythm that may be serious and potentially life-threatening (3) The use of Haloperidol combined with Zofran can increase the risk of an irregular heart rhythm that may be serious and potentially life-threatening. During the review of the patient's record, there was no communication found within the patient's record, or within documentation of the IDT (Interdisciplinary Team) meetings that a major drug interaction was identified, communicated, or resolved. MR#3: The Start of Care was dated 1/18/2022. The patient was admitted with diagnoses of Heart Failure, End Stage Renal Disease, Need for assistance with Personal Care, Shortness of Breath, Hallucinations, Anorexia, and Disorientation. Upon review of the patient's drug profile and medication review via "Drugs.com," four (4) major drug interactions were identified as follows: (1) Using Haloperidol with Erythromycin results in the risk of irregular heart rhythm; (2) the use of Potassium Chloride together with Dicyclomine may increase the irritant effects of potassium on the stomach and upper intestine which can result in ulcers, bleeding, and other gastrointestinal injury. (3) The use of Erythromycin together with Atorvastatin can increase blood levels of atorvastatin which may result in liver damage and rhabdomyolysis; and (4) The Combination of Trimethoprim and potassium chloride can result in an increase of potassium levels in the blood. High levels of potassium can develop into a condition known as hyperkalemia, which in severe cases can lead to kidney failure, muscle paralysis, irregular heart rhythm, and cardiac arrest. During the review of the patient's record, there was no communication found within the patient's record, or within documentation of the IDT (Interdisciplinary Team) meetings that a major drug interaction was identified, communicated, or resolved. MR#4: The Start of Care was dated 8/3/2021, The patient was admitted with diagnoses of Alcoholic cirrhosis of liver with ascites, Sepsis, Bed Confinement Status, Low Back Pain, Urinary Incontinence, Disorientation, Chronic Kidney Disease Stage 3, Severe protein-calorie malnutrition, Diabetes Type 2, and Esophageal Varices. Upon review of the patient's drug profile and medication review via "Drugs.com," four (4) major drug interactions were identified as follows: Upon review of the patient's drug and medication review, a major interaction was discovered between the patient's 2 prescribed drugs as follows: The patient was currently prescribed 2 drugs, Morphine Sulfate and Norco. The drug review via drug.com revealed that narcotic pain medications such as Morphine used together with other medications that also cause central nervous system depression such as Norco, can lead to serious side effects including respiratory distress, coma, and even death. During the review of the patient's record, there was no communication found within the patient's record, or within documentation of the IDT (Interdisciplinary Team) meetings that a major drug interaction was identified, communicated, or resolved. MR#5. The Start of Care was dated 1/14/22. The Plan of Care identified diagnoses of Mesothelioma, Hypertension, Mitral Valve Prolapse, Cardiomyopathy, Shortness of Breath, and Pain. Upon review of the patient's drug and medication review, 3 major interactions were identified via Drugs.com as follows: (1) Using Haloperidol together with Morphine can lead to serious side effects including respiratory distress, coma, and even death; (2) The use of Haloperidol combined with Compazine can increase the risk of an irregular heart rhythm that is potentially life-threatening; (3) The combined use of Haloperidol with Ondansetron can increase the risk of an irregular heart rhythm. During the review of the patient's record, there was no communication found within the patient's record, or within documentation of the IDT (Interdisciplinary Team) meetings that a major drug interaction was identified, communicated, or resolved. MR#6: The Start of Care was dated 1/15/22. The patient was admitted with diagnoses of Covid-19, dementia, and dysphagia. Upon review of the patient's drug and medication review, a major interaction was discovered between the patient's 2 prescribed drugs as follows: Haloperidol and Morphine. Using narcotic pain or cough medications together with other medications that also cause central nervous system depression can lead to serious side effects including respiratory distress, coma, and even death. During the review of the patient's record, there was no communication found within the patient's record, or within documentation of the IDT (Interdisciplinary Team) meetings that a major drug interaction was identified, communicated, or resolved. This finding was reviewed and acknowledged by the Administrator (ADM#1) during an interview on 2/10/21 at 1:30 p.m. MR #8: The patient's start of care (SOC) was 1/12/22 with a terminal diagnosis of Exacerbation of Chronic Obstructive Pulmonary Disease (COPD). The clinical record review was conducted on 2/8/22 at 2:43 p.m. The "Initial Comprehensive Assessment" dated 1/12/22, completed by the Registered Nurse documented, "Pharmacy collaboration for medication mngmt (management)..., Review current list of medications for dosing, purpose, and side effects with patient/family/ MD, NP, LTC staff, and caregivers - Assessed." The patient's prescribed medications were entered in the Agency's "Medscape Drug Reference Database" (Drug Interaction Report system) and revealed 4 Serious - (Use Alternative), drug to drug interactions and a total of 50 drug interactions. Upon further review, there was no evidence that the agency had conducted a drug review, and no documented evidence that the Physician had been informed of the untoward drug interactions. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and the Director of Clinical Services (DCS #1) during an interview on 2/9/22 at 2:50 p.m. MR #9: The patient's SOC was 11/13/21 with a terminal diagnosis of Alzheimer's Disease and Covid related Pneumonitis. The patient's prescribed medications were entered in the Agency's Medscape Drug Reference Database and revealed 1 Serious - Use Alternative, drug to drug interaction and a total of 5 drug interactions. Upon further review, there was no documented evidence that the Agency had conducted a drug review and no documented evidence that the Physician had been informed of the untoward drug interactions. These findings were reviewed with and acknowledged by Adm #1 and DCS #1 during an interview on 2/9/22 at 3:07 p.m. MR #10: The patient's SOC was 1/7/22 with a terminal diagnosis of Lung Cancer. The patient's prescribed medications were entered in the Agency's Medscape Drug Reference Database and revealed 1 Serious - Use Alternative, drug to drug interaction and a total of 5 drug interactions. Upon further review, there was no documented evidence that the Agency had conducted a drug review and no documented evidence that the Physician had been informed of the untoward drug interactions. These findings were reviewed with and acknowledged by Adm #1 and DCS #1 during an interview on 2/9/22 at 3:15 p.m. MR #11: The patient's SOC was 2/3/22 with terminal diagnoses that included Intracranial Hemorrhage and Alzheimer's Disease. The Initial Comprehensive Assessment dated 2/3/22 completed by the RN, made no mention of the Drug Review process. The patient's prescribed medications were entered in the Agency's Medscape Drug Reference Database and revealed 1 Serious - Use Alternative, drug to drug interaction and a total of 3 drug interactions. Upon further review, there was no documented evidence that the Agency had conducted a drug review and no documented evidence that the Physician had been informed of the untoward drug interactions. These findings were reviewed with and acknowledged by Adm #1 and DCS #1 during an interview on 2/9/22 at 3:18 p.m. MR #13: The patient's SOC was 11/3/21 with a terminal diagnosis of End Stage COPD. The Initial Comprehensive Assessment dated 11/3/21 completed by the RN, made no mention of the Drug Review process. The patient's prescribed medications were entered in the Agency's Medscape Drug Reference Database and revealed 1 Serious - Use Alternative, drug to drug interaction and a total of 2 drug interactions. Upon further review, there was no documented evidence that the Agency had conducted a drug review and no documented evidence that the Physician had been informed of the untoward drug interactions. These findings were reviewed with and acknowledged by Adm #1 and DCS #1 during an interview on 2/10/22 at 9:30 a.m. **When conducting the onsite drug review utilizing the agency's Medscape system, it was noted that the system would not allow entry of all the patient's prescribed medications in order to determine any untoward interactions. It was therefore determined that the agency failed to conduct an accurate, comprehensive review of all the patent's medications. **On 2/9/22 at 3:50 p.m. during an interview, DCS #1 was queried about the process for conducting the drug review and reported, "I think Enclara, (a national full-service PBM (Pharmacy Benefit Managers) and mail order supplier of medications), our Pharmacist does the drug review. The nurses put the drugs in Enclara and the pharmacy does the review. If there are interactions, the drugs are not sent." When asked if there was any documented evidence of this process, DCS #1 reported, "There should be. I'll get the nurse (RN #3) who handles this." **On 2/9/22 at 4:01 p.m., an interview was conducted with the Registered Nurse (RN #3) who reported, "Enclara does the review (of the medications) and calls me with the results." When asked if there was documentation of this process, RN #3 reported, "I don't document anything. The Doctor already knows about the medications. I mean, they're usually the same 2 drugs, Haldol (used to treat terminal delirium, severe agitation in end-stage dementia) and Zofran (used to manage nausea and vomiting). I can also use my knowledge of the medications or use a drug book to see if there are interactions." There was no evidence that the Agency had conducted a comprehensive drug review of all the patient's medications in order to ascertain any untoward drug interactions, and no documented evidence that the Physician had been notified accordingly.

Based on record review and interview, it was determined that the Hospice failed to ensure the comprehensive assessment included an initial bereavement assessment that included the identification of the potential bereaved individuals, and the social, spiritual and cultural factors that may impact their ability to cope with the patient's death in 5 (MR's #8, 9, 10, 11, 12) of 6 records that required a bereavement assessment, from a total sample of 13 sampled records reviewed, with 2 additional bereavement records, resulting in the potential for ineffective grieving and lack of bereavement support for the family members and caregivers upon the patient's death. Findings include: MR #8: The patient was admitted to Hospice on 1/12/22 with terminal diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure. On 2/8/22 at 2:43 p.m., during a review of the patient's Initial Bereavement Assessment, it was noted that the narrative mentioned the patient's daughter-in-law and son. The section titled "Bereavement", which determined the level of identified risk, did not list any of the potential bereaved parties. MR #9: The patient was admitted to Hospice on 11/13/21 with terminal diagnoses of Alzheimer's Disease and Covid related Pneumonitis. On 2/8/22 during the clinical record review, it was noted that the patient's contacts listed 2 daughters, 1 son, 1 granddaughter and another family member. The patient's Initial Bereavement Assessment, dated 11/18/21, failed to include any of the above contacts. MR #10: The patient was admitted to Hospice on 1/7/22 with a terminal diagnosis of Lung Cancer. The patient subsequently passed away on 2/1/21. On 2/9/22 during the record review, it was noted that section that identified the person or persons who would be affected by the persons death was void of any names. The patient's contact list included the patient's husband and daughter. Additionally, the Social Worker's (MSW #1) narrative documented, "the family in the home includes a daughter and a granddaughter age 10..., a son and a brother who lives next door. There was no acknowledgement of all the family members who would be affected upon the patient's death. MR #11: The patient was admitted to Hospice on 2/3/22 with a terminal diagnosis of Intracranial Hemorrhage. During the record review on 2/9/22 at 11:13 a.m., it was noted that Patient's contacts listed the patient's wife and 3 sons. The Initial Bereavement Assessment documented, "some support apparent or caring persons..." The Bereavement Assessment was void of all parties names who would be affected upon the patient's death. MR #12: the patient was admitted to Hospice on 1/14/22 with terminal diagnoses that included COPD, Covid-19 and Respiratory Failure. The record review was conducted on 2/9/22 at 1:04 p.m. The patient's contact list revealed that the patient had 2 daughters that were active in the patient's life. The Initial Bereavement Assessment visit was dated 1/15/22. SW #1's narrative read, "The primary caregiver (daughter #1) is with the family's Pastor... Daughter #2 is attending to the patient. Daughter #1 stated she is tired and short tempered. Daughter #1 is tearful..., Other family is present and helping with the patient's care..." There was no indication that all the above mentioned parties had been included in the Bereavement Assessment process to receive grief support upon the patient's death. The findings in the above-mentioned records were reviewed with and acknowledged by the Administrator (Adm #1) and the Director of Clinical Services (DCS #1) during an interview on 2/9/22 and again during the exit conference on 2/10/22.

Based on record review and interview, the Hospice failed to ensure that care and services met the needs for 1 of 1 patient (MR #13) who had a newly identified raised area with swelling to his right foot, and failed to ensure that care was coordinated within the Interdisciplinary Group, from a total of 13 sampled records reviewed, resulting in an undiagnosed, untreated health condition and unmet care needs. Findings include: MR #13: The patient's SOC was 11/3/21 with a terminal diagnosis of End Stage Chronic Obstructive Pulmonary Disease (COPD). During the clinical record review on 2/9/22 at 2:10 p.m., it was noted the Initial comprehensive Assessment dated 11/3/21, completed by the Registered Nurse (RN), titled "Skin/Circulation" documented, "erythema (redness) to thoracic spine... skin breakdown." No other skin issues had been identified at the time of admission. An Aide visit note dated 12/28/21 and timed for 1:00 p.m. to 1:45 p.m. documented, "Right foot a little swollen..." There was no documented evidence that the Aide reported these findings to the assigned Case Manager. A Registered Nurse (RN) Phone Call note dated 12/28/21 and timed for 6:30 p.m. documented, "Daughter explained he (patient) had some swelling to his right foot so they called the ambulance to come assess..., RN explained discharge was taking place tomorrow and completely effective 12/31." There was no documented evidence that the RN followed up and assessed the patient's newly identified swelling. Further, there was no documented evidence that the patient's change in condition was reported to the Physician or any of the Interdisciplinary Group members. These findings were discussed with the Director of Clinical Services (DCS #1) during an interview on 2/10/22 at 12:55 p.m. who reviewed the clinical record and reported, "You're right. The Aide didn't notify the Nurse, and I don't see that she (RN) notified the Physician."

Based on record review and interview, the hospice failed to ensure the plan of care included goals/outcomes for hospice care that were measurable and enabled staff to accurately perform an objective evaluation of the patients' progress toward goals for 7 of 13 records reviewed, (MR#s 1, 2, 3, 4, 5, 6, and 7), from a total sample of 13 records reviewed, resulting in the inability of staff to accurately perform an objective evaluation of the patients' progress toward goals. Findings included: **Agency Policy: interdisciplinary Team Meeting (Policy No.:2-006.1) states, "The interdisciplinary Plan of Care Update will note the status of the patient/caregiver as well as changes in the Plan of Care, which may include: ...Measurable outcomes." MR#1: The Start of Care was dated 1/28/22. The patient was admitted with diagnosis of Renal Failure, Chronic Kidney Disease stage 4, (CKD4), Congestive Heart Failure (CHF), Hypertension (HTN), and Peripheral Vascular Disease (PVD). Upon review of the patient visit notes, comprehensive assessment, and IDG (interdisciplinary group) documentation, there was no evidence that the goals on Plans of Care were measurable. Examples include: "Pain is currently managed at a level acceptable to patient by the end of visit; Patient will have personal care needs by CNA according to schedule; Wound care to be completed by CNA and/or Caregiver." These goals are not objectively measurable to determine the patient's progress towards goals/outcomes." MR#2: The Start of Care was dated 1/23/2022. The patient was admitted with diagnoses of Malignant neoplasm of Ovary, Covid-19, Hypertension (HTN), Diabetes type 2 (DM2), and Pulmonary Fibrosis. Upon review of the patient visit notes, comprehensive assessment, and IDG (Interdisciplinary Group) documentation, there was no evidence that the goals on the Plans of Care were appropriate, or objectively measurable to determine progress towards goals/outcomes. Examples include: "Pt/Family/POA/Caregiver will voice understanding of Wings of Hope Hospice philosophy and voice agreement to the Initial Plan of Care; Pain is currently managed at a level acceptable to patient by end of visit; Patient will have personal care needs assisted by CNA according to schedule; Patient and/or patient caregiver/family demonstrate healthy coping skills for grief and loss.: These goals are not objectively measurable to determine the patient's progress towards goals. MR#3: The Start of Care was dated 1/18/2022. The patient was admitted with diagnoses of Heart Failure, End Stage Renal Disease, Need for assistance with Personal Care, Shortness of Breath, Hallucinations, Anorexia, and Disorientation. Upon review of the patient visit notes, comprehensive assessment, and IDG (Interdisciplinary Group) documentation, there was no evidence that the goals on the Plans of Care were appropriate, or objectively measurable to determine progress towards goals/outcomes. Examples include: "Caregiver will verbalize understanding of expected disease progression and the signs/symptoms of impending death during the visit; Patient will have personal care needs assisted by CNA (Certified Nursing Assistant) according to schedule; Patient receives effective management of anxiety." These goals are not objectively measurable to determine the patient's progress towards goals. MR#4: The Start of Care was dated 8/3/2021, The patient was admitted with diagnoses of Alcoholic cirrhosis of liver with ascites, Sepsis, Bed Confinement Status, Low Back Pain, Urinary Incontinence, Disorientation, Chronic Kidney Disease Stage 3, Severe protein-calorie malnutrition, Diabetes Type 2, and Esophageal Varices. Upon review of the patient visit notes, comprehensive assessment, and IDG (Interdisciplinary Group) documentation, there was no evidence that the goals on the Plans of Care were appropriate, or objectively measurable to determine progress towards goals/outcomes. Examples include: "End of Life goals are achieved to satisfaction of the patient; Coping Adjustment goals met; Other: Specify in Comments (there were no comments found in the chart)." These goals are not objectively measurable to determine the patient's progress towards goals, and there were no comments that applied to the goal of "other". MR#5: The Start of Care wad dated 1/14/2022. The patient was admitted with Diagnoses of Mesothelioma, Nonrheumatic mitral valve prolapse, Hypertension, Cardiomyopathy, Shortness of Breath, and Pain. Upon review of the patient visit notes, comprehensive assessment, and IDG (Interdisciplinary Group) documentation, there was no evidence that the goals on the Plans of Care were appropriate, or objectively measurable to determine progress towards goals/outcomes. Examples include: "Hospice RN will coordinate care for patient with all members of the IDG (Interdisciplinary Group) as documented in the medical record each IDT period. "This is not a goal specifically for the patient, but a goal for the nurse and hospice. MR 6: The Start of Care was dated 1/15/2022. The patient was admitted with diagnoses of Covid-19 and Vascular Dementia. Upon review of the patient visit notes, comprehensive assessment, and IDG (Interdisciplinary Group) documentation, there was no evidence that the goals on the Plans of Care were appropriate, or objectively measurable to determine progress towards goals/outcomes. Examples include: "Patient/Family/Power of Attorney/ Caregiver will voice understanding of Wings of Hope Hospice philosophy and voice agreement to the Initial Plan of Care; Patient remains safe and cared for during caregiver crisis; Caregiver expresses feelings associated with losses." These goals are not objectively measurable to determine the patient's progress towards goals. MR#7: The Start of Care was dated 1/27/2022. The patient was admitted with diagnoses of Heart Failure, Chronic Kidney Disease Stage 4, and Edema. Upon review of the patient visit notes, comprehensive assessment, and IDG Interdisciplinary Group) documentation, there was no evidence that the goals on the Plans of Care were appropriate, or objectively measurable to determine progress towards goals/outcomes. Examples include: "Wound care to be completed by CNA (certified nurse aide) or caregiver (this is an intervention, not a goal); End of Life Goals are achieved to satisfaction of patient." These goals are not objectively measurable to determine the patient's progress towards goals.

Based on documents reviewed, and interview, the hospice failed to ensure that the frequency and detail of data collection for the QAPI program was reviewed and approved by the governing body. Findings Included: On 2/9/2022, the minutes of the 12 Governing Board meetings dated between December 3, 2020 and December 3, 2021 were reviewed. The meeting minutes failed to show a review and approval by the Governing Body of the frequency and detail of the hospice's QAPI data measures and collection. These findings were confirmed during an interview with the Administrator (ADM#1) on 2/9/2022 at 3:00 p.m. After a brief review of the Governing Board meeting minutes for the year 2021, it was agreed upon by ADM#1 that there was no documented approval of the QAPI program frequency and detail of data collection for the QAPI program for the year 2022.

Based on the record review and interview, it was determined the Hospice failed to make bereavement services available to the bereaved family member up to 1 year following the death of the patient in 1 (BRV #14) of 2 bereavement records, and failed to complete a bereavement plan of care that listed the bereaved family members, and the frequency of service delivery in 2 (BRV #14 and BRV #15) of 2 bereavement records, resulting in the potential for ineffective coping/grieving and unmet bereavement needs. Findings include: BRV #14: The patient was admitted to Hospice on 2/2/21 with a terminal diagnosis of Malignant Neoplasm and subsequently passed away on 2/28/21. During an interview with the Bereavement Coordinator (BC #1) on 2/8/22 at 10:06 a.m., a request was made to review 2 Bereavement records. Upon review of BRV #14, it was noted that the last contact made to the bereaved was 9/9/21. The Bereavement POC was scheduled to close out in March of 2022. The Agency had not made contact with the bereaved in 5 months. These findings were reviewed with and acknowledged by BC #1 at the time of discovery. Further review of the Bereavement POC revealed the bereaved family member was not listed and there were no frequencies in which contact would be made or when services would be provided. BRV #15: The patient was admitted to Hospice on 8/7/20 with a terminal diagnosis of Leukemia and subsequently passed away on 8/15/20. During a review of the clinical record, it was noted that the deceased had very close relationships with his wife, son, 2 daughters, a sister and another listed family member. Upon review of Bereavement POC, it was noted that there were no one listed who would receive bereavement services or the frequency in which services would be provided. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and the Director of Clinical Services (DCS #1) during the exit interview on 2/10/22

Based on record review and interview, the Registered Nurse failed to ensure the written plan of care for the assigned Hospice Aides provided specific guidance and care instructions on the needs of the patient, for 10 (MR's #1, 2, 3, 4, 6, 7, 9, 10, 12, 13) of 10 records with Hospice Aide services ordered from a total of 13 records reviewed resulting in the potential for unmet care needs and poor patient outcomes. Findings include: Policy: "Hospice Aide Services", Policy No: 4-008.1, undated, unsigned stated, "These activities will be assigned and supervised by a Registered Nurse, in accordance with the Interdisciplinary Plan of Care." MR #9: The patient's Start of Care (SOC) was 11/13/21. The period of review was 1/12/22 with a terminal diagnosis of Alzheimer's Disease and Covid related Pneumonitis. The clinical record was reviewed on 2/8/22 and revealed, Hospice Aide services were ordered at a frequency of 2x/wk. Upon review of the "CNA (HHA) Assignment" (Aide Care Plan), the Registered Nurse (RN) failed to indicate the frequency of visits to be made or the frequency in which each task was to be carried out. Additionally, the Aide Care Plan was void of the patient's name and the name of the assigned Hospice Aide. MR #10: The patient's SOC was 1/7/22 with a terminal diagnosis of Lung Cancer. During the record review on 2/9/22, it was noted that Aide services were ordered at a frequency of 2x/wk. There was no guidance on the Aide Care Plan regarding visit frequency or frequency in which tasks were to be performed. Additionally, the Aide Care Plan was void of the patient's name and the name of the assigned Hospice Aide. MR #12: The patient's SOC was 1/14/22 with terminal diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), Covid-19 and Respiratory Failure. The POC ordered Aide services at a frequency of 5x/wk. The Aide Care Plan was void of frequency of visits to be made and tasks to be performed. Additionally, the Aide Care Plan was void of the patient's name and the name of the assigned Hospice Aide. MR #13: The patient's SOC as 11/3/21 with a terminal diagnosis of End Stage COPD. The record review was conducted on 2/9/22 at 2:10 p.m. and revealed that Aide services were ordered for 1x/wk. The Initial Comprehensive Assessment dated 11/3/21, completed by the Registered Nurse (RN) documented, "erythema redness) to thoracic spine curvature -skin breakdown." The Aide Care Plan was void of this information. Additionally, the Aide Care Plan provided no guidance on the frequency in which tasks were to be performed. Additionally, the Aide Care Plan was void of the patient's name and the name of the assigned Hospice Aide. On 2/20/22 at 9:29 a.m., an interview was conducted with the Hospice Aide (HA #2). When asked if she was aware of the frequency of visits or frequency of tasks to be carried out when caring for patients, HA #2 acknowledged that the Aide Care Plan did not provide this information and more clearly stated, "No, I can't tell by looking at this care plan." These findings were reviewed with the Director of Clinical Services who was present during the interview with HA #2. MR#1: The Start of Care was dated 1/28/22. The patient was admitted with diagnoses of Renal Failure, Chronic Kidney Disease stage 4, (CKD 4), Congestive Heart Failure (CHF), Hypertension (HTN), and Peripheral Vascular Disease (PVD). On 2/7/22, the clinical record was reviewed. Orders for Aide Services included the frequency of visits at 3x/week. It was noted upon review that the Aide Care Plan failed to include the frequency of visits per week, and the frequency in which each assigned task was to be performed. In addition, the Aide Care Plan failed to include the names of the patient and the Aide. MR#2: The Start of Care was dated 1/23/2022. The patient was admitted with diagnoses of Malignant neoplasm of Ovary, and Covid-19, Hypertension, and Diabetes Type 2. On 2/8/2022, The clinical record was reviewed. Orders for Aide services included the frequency of visits at 2x/week. It was noted upon review that the Aide Care Plan failed to include the frequency of visits per week, and the frequency in which each assigned task was to be performed. In addition, the Aide Care Plan failed to include the names of the patient and the Aide. MR#3: The Start of Care was dated 1/18/2022. The patient was admitted with diagnoses of Heart Failure, End Stage Renal Disease, Need for assistance with Personal Care, Shortness of Breath, Hallucinations, Anorexia, and Disorientation. On 2/8/2022, The clinical record was reviewed. Orders for Aide services included the frequency of visits at 1x/week. It was noted upon review that the Aide Care Plan failed to include the ordered frequency of visits per week, and the frequency in which each assigned task was to be performed. In addition, the Aide Care Plan failed to include the names of the patient and the Aide. MR#4: The Start of Care was dated 8/3/2021, The patient was admitted with diagnoses of Alcoholic cirrhosis of liver with ascites, Sepsis, Bed Confinement Status, Low Back Pain, Urinary Incontinence, Disorientation, Chronic Kidney Disease Stage 3, Severe protein-calorie malnutrition, Diabetes Type 2, and Esophageal Varices. The clinical record was reviewed. Orders for Aide services included the frequency of visits at 2x/week for 1 week then 1x/week beginning 8/8/21. It was noted upon review that the Aide Care Plan failed to include the frequencies of visits per week, and the frequency in which each assigned task was to be performed. In addition, the Aide Care Plan failed to include the names of the patient and the Aide. MR 6: The Start of Care was dated 1/15/2022. The patient was admitted with diagnoses of Covid-19 and Vascular Dementia. Review of the clinical record documented the frequency of Aide Services 2x/week x 1 week, then 1x/week thereafter. It was noted upon review that the Aide Care Plans failed to include the frequencies of visits per week, and the frequency in which each assigned task was to be performed. In addition, the Aide Care Plan failed to include the names of the patient and the Aide. MR#7: The Start of Care was dated 1/27/2022. The patient was admitted with diagnoses of Heart Failure, Chronic Kidney Disease Stage 4, and Edema. A review of the clinical record revealed Aide Services were ordered for 2x/week. It was noted upon review that the Aide Care Plan failed to include the frequency of visits per week, and the frequency in which each assigned task was to be performed. In addition, the Aide Care Plan failed to include the names of the patient and the Aide. These findings were reviewed and acknowledged by the Administrator (ADM#1) during an interview on 2/10/2022 at 1:30 p.m.

Based on record review and interview, the agency failed to ensure the hospice aide (HA) accurately documented the care given, and provided visits as ordered for the required visit frequency for 1 (MR#1) of 1 record, and failed to ensure the Aide reported a change in condition for 1 (MR #13) of one patient identified with swelling to right foot, from 8 patients ordered to receive Aide services, from a total sample of 13 sampled records reviewed, resulting in the inability of the agency to ensure patients received appropriate hospice Aide care and services. Findings included: MR#1: The Start of Care was dated 1/28/22. The patient was admitted with diagnosis of Renal Failure, Chronic Kidney Disease stage 4, (CKD4), Congestive Heart Failure (CHF), Hypertension (HTN), and Peripheral Vascular Disease (PVD). The Plan of Care included orders for Aide services 3 times per week. Upon review of the record on 2/7/22, it was noted that the aide visit note dated 2/7/22 included the following documentation: "Visit refused by family." However, further review of the Aide visit note summary documented "All care done according to plan of care." This finding was reviewed and acknowledged by the Administrator (Adm #1) on 2/10/21 at 1:30 p.m. MR #13: The patient's SOC was 11/3/21 with a terminal diagnosis of End Stage Chronic Obstructive Pulmonary Disease (COPD). During the clinical record review on 2/9/22 at 2:10 p.m., it was noted that the section of the Initial comprehensive Assessment dated 11/3/21 completed by the Registered Nurse (RN), titled "Skin/Circulation" documented, "erythema (redness) to thoracic spine... skin breakdown." No other skin issues had been identified at the time of admission. An Aide visit note dated 12/28/21 documented, "Right foot a little swollen..." There was no documented evidence that the Aide reported these findings to the assigned Case Manager. These findings were discussed with the Director of Clinical Services (DCS #1) during an interview on 2/10/22 at 12:55 p.m. who reviewed the clinical record and reported, "You're right. The Aide didn't notify the Nurse. It should have been reported."

Based on record review and interview, the agency failed to ensure the information in the clinical record was accurate in 1 of 13 records reviewed (MR#2) out of a total of 13 records reviewed, resulting in the potential for patient needs not being met or incorrect care being provided. Findings included: Agency Policy# 7-012.1, Entries into Clinical Records, no date. The Policy states, "Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided." MR#2: The Start of Care was dated 1/23/2022. The patient was admitted with diagnoses of Malignant neoplasm of Ovary, Covid-19, Hypertension (HTN), Diabetes type 2 (DM2), and Pulmonary Fibrosis. Upon review of the Comprehensive Assessment dated 1/23/2022, the Registered Nurse documented the patient's Height and Weight as follows: "Height: 5 feet/4 inches; Weight: 22 pounds." These findings were reviewed and acknowledged by the Administrator (ADM#1) during an interview on 2/10/2022 at 1;00 p.m.

Based on record review and interview, it was noted that the visit notes for each of the 13 patient chart reviews MR#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, including all disciplines (Registered Nurses, Hospice Aides, Medical Social Workers, Spiritual Counselors, and Administrative Directors) that provided care or services to the patients, were not authenticated in 13 of 13 records reviewed resulting in not having knowledge of the author of each visit note who provided care to the patient. Findings included: **Agency Policy #7-012.1, "Entries into Clinical Records", no date. The policy states, "Entries in the clinical record will be made only by the staff and/or by authorized contract personnel and will include the date care/service provided. The entries will be documented by the first initial of the given name, full surname, and title or credentials. Initials may be used on forms where authentication signature space is designated on the form." Example#1: MR#2: The Start of Care was dated 1/23/2022. The patient was admitted with diagnoses of Malignant neoplasm of Ovary, Covid-19, Hypertension (HTN), Diabetes type 2 (DM2), and Pulmonary Fibrosis. Upon review of the 19 visit notes for this patient which included visit notes from Registered Nurses, Licensed Practical Nurses, Hospice Aides, Medical Social Workers, Spiritual Counselors and Administrative Directors failed to document the name of the person who evaluated the patient and completed the visit note to authenticate the clinical record. Each visit note or communication merely documented the discipline without a name or signature. This finding was reviewed and acknowledged during an interview with the agency IT specialist (DCS#1) on 2/8/22 at 11:30 a.m. The surveyor asked, where to find the name of the person who submitted the visit notes? The IT specialist said, "the names of the personnel who are assigned to the patient and completed the visit notes will appear on the face sheet." The IT specialist further stated "I have already been advised during this survey that the Hospice Agency's Electronic Medical Record was not sufficient for required documentation of Hospice activities." It was noted upon review of the face sheet for MR#2, there were 4 different Registered Nurses (RNs) assigned to the patient making it difficult to determine which of the 4 RNs had performed the assessments and completed the visit notes. The visit notes merely documented the discipline of the person who provided the care. Example #2: MR#6: The Start of Care was dated 1/15/22. The patient was admitted with diagnoses of Covid-19 pneumonia, urinary incontinence, dysphagia, and dementia. This patient expired at home on 1/24/2022. The events of the evening were documented as follows: Documentation included "a Licensed Practical Nurse (LPN) visit per telephone call on 1/24/2022 at 7:30 PM and another LPN phone visit on the same date of 1/24/2022 at 8:30 PM. Additionally, the LPN documented a Discharge Visit on 1/24/22 at 9:30 PM with the following patient visit summary note: "Discharge visit: Call from Daughter that she thought the patient had passed." Upon arrival to the home the LPN documented ".....assessed patient without vital signs, medical director notified, funeral home notified of death, care link answering service notified of need for pick up of "OBT" & hospital bed." Medications wasted per protocol, family grieving, notified that the Bereavement Coordinator would be in contact within the next few weeks. IDG (Interdisciplinary Group) informed." However, there was no indication in the record of the name of the LPN who had advised the patient via the 2 phone calls at 7:30 and 8:30 PM, nor was there a signature found in the electronic record for this patient that authenticated the name of the LPN who had completed end-of-life care for this patient. A review of the Wings of Hope Organizational Chart indicates the agency employs 2 LPN Case Managers, 1 LPN night nurse, and 1 LPN Triage/Visit Nurse. There was no specific name of any LPN's listed on the face sheet to indicate which of the 4 LPNs was providing nursing services to this patient on 1/24/2022. The agency failed to authenticate the care given to the patient/family by any of the 4 LPNs on the evening of 1/24/2022. This finding was reviewed and acknowledged by the Administrator (ADM#1) on 2/10/22 at 1:30 p.m.

Based on record review and interview, it was determined that the Hospice failed to ensure a Discharge Summary was completed, detailed the course of care provided, including symptom and pain management, Physician's orders and the patient's health status at the time of discharge for 1 (MR #13) of 1 patient who was discharged to the community, from a total of 13 sampled records reviewed, resulting in the potential for unmet care needs and interruption in post-discharge continuity of care. Findings include: Policy: Discharge Summary, undated or signed, Policy No: 7-014.1 stated, "All patients discharged from Wings of Hope will have a Discharge Summary completed and filed in the clinical record. The Discharge Summary is completed and submitted within 14 days of the discharge..., Staff who provide care will complete a discharge summary at the time of discharge which includes: date of discharge, reason for discharge, problems identified at admission and during the provision of care, overall status of the patient, summary of care or services provided, a copy of the discharge summary will be provided to the patient's physician..." MR #13: The patient was admitted to Hospice on 11/3/21 with a terminal diagnosis of End Stage Chronic Obstructive Pulmonary Disease (COPD). During the clinical record review on 2/9/22 at 2:10 p.m., it was noted that the Plan of Care (POC) ordered Skilled Nursing (SN), Aide services and Medical Social Work (MSW) services to be provided. The patient was discharged to he community on 12/31/21. At the time of this review, no discharge summaries had been completed by the SN or MSW and forwarded to the Physician in order to assist with Post Discharge Continuity of Care. During an interview on 2/10/22 at 12:52 p.m., the Director of Clinical Services (DCS #1) presented a section of a Nursing visit note dated 12/29/21 and stated, "This is the Discharge Summary. The note documented, "RN explained discharge to pt (patient) and had pt sign papers that pt was no longer eligible. RN explained why pt is not appropriate for hospice. RN left copies of paper work for pt..." At the time of this record review, no Discharge Summaries had been completed by any of the ordered disciplines.

Based on record review and interview, it was determined that the Hospice failed to assume responsibility for the hospice services provided in accordance with the Hospice plan of care in 2 (MR's #9 and 11) of 2 records of patients who resided in a Skilled Nursing Facility, from a total of 13 sampled records reviewed, resulting in lack of oversight and uncoordinated care and services and the potential for unmet care needs (L762); failed to ensure that all care provided was in accordance with the written Hospice Plan of Care in 2 (MR's #9 and 11) of 2 records of patients who resided in a Skilled Nursing Facility, from a total of 13 sampled records reviewed, resulting in the potential for unmet care needs (L773); failed to identify the care and services that were needed and identify each provider's responsibility for performing the needed functions that had been agreed upon and included in the hospice plan of care in 2 (MR's #9 and 11) of 2 records of patients who resided in a Skilled Nursing Facility, from a total of 13 sampled records reviewed, resulting in the potential for needed care and services to be overlooked and unmet care needs (L774); failed to ensure the Hospice plan of care reflected the collaborative participation of the Hospice, Skilled Nursing Facility and the patient/family in 2 (MR's #9 and 11) of 2 records reviewed in which the patients resided in a nursing home, resulting in the potential for ineffective coordination of care and unmet care needs (L775); and failed to ensure that staff Skilled Nursing Facility received orientation and training regarding the Hospice Philosophy and the needs of the Hospice patient in 2 (MR's #9, 11) of 2 records of patients who resided in a Skilled Nursing Facility, from a total of 13 records reviewed, resulting in the potential for unmet care needs at the end of life (L782). The cumulative effect of these systemic problems resulted in the agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation 42 CFR §418.112 Hospices that provide hospice care to residents of a SNF/NF or ICF/MR (facility).

Based on record review and and interview, the Hospice Agency failed to assume responsibility for the hospice services provided in accordance with the Hospice plan of care in 2 (MR's #9 and 11) of 2 records of patients who resided in a Skilled Nursing Facility, from a total of 13 sampled records reviewed, resulting in lack of oversight and uncoordinated care and services and the potential for unmet care needs. Findings include: Hospice Agreement: dated 8/6/15, stated, "Hospice shall retain professional management responsibility to ensure that Hospice Services are furnished in a safe and effective manner by qualified personnel in accordance with Hospice patient's Plan of Care." MR #9: The patient was admitted to Hospice on 11/13/21. The period of review was 1/12/22 through 2/10/22 with terminal diagnoses that included Alzheimer's Disease and Covid related Pneumonitis. The patient resided in a Skilled Nursing Facility (SNF). During the clinical record review on 2/8/22 it was noted that the Hospice plan of care (POC) ordered Skilled Nursing (SN), Aide services, Spiritual Care (SC) and Medical Social Work (MSW) services to be provided. MR #11: The patient was admitted to Hospice on 2/3/22 with terminal diagnoses that included Intracranial Hemorrhage and Alzheimer's Disease. The patient resided in a SNF. During the record review on 2/9/22 at 11:13 a.m., it was noted that the Hospice POC ordered SN, Aide services, SC and MSW services to be provided. On 2/9/22 at 10:25 a.m., a request was made to the Director of Clinical Services (DCS #1) to receive copies of the above patient's records, including care plans, from the Skilled Nursing Facility (SNF). Upon receipt and review, it was noted that the care plans had been generated by the SNF. There was no Hospice Plan of Care available for review as the patient's Hospice POC had not been provided to the SNF. The Hospice Agency failed to assume responsibility for the Hospice services provided in accordance with the Hospice plan of care. These findings were reviewed with DCS #1 during an interview on 2/9/22 at 2:20 p.m.

Based on record review and and interview, the Hospice Agency failed to ensure that all care provided was in accordance with the written Hospice Plan of Care in 2 (MR's #9 and 11) of 2 records of patients who resided in a Skilled Nursing Facility, from a total of 13 sampled records reviewed, resulting in the potential for unmet care needs. Findings include: Hospice Agreement: dated 8/6/15, stated, "Hospice retains primary responsibility for development of the Plan of Care." professional management responsibility to ensure that Hospice Services are furnished in a safe and effective manner by qualified personnel in accordance with Hospice patient's Plan of Care." MR #9: The patient was admitted to Hospice on 11/13/21. The period of review was 1/12/22 through 2/10/22 with terminal diagnoses that included Alzheimer's Disease and Covid related Pneumonitis. The patient resided in a Skilled Nursing Facility (SNF). During the clinical record review on 2/8/22 it was noted that the Hospice plan of care (POC) ordered Skilled Nursing (SN), Aide services, Spiritual Care (SC) and Medical Social Work (MSW) services to be provided. MR #11: The patient was admitted to Hospice on 2/3/22 with terminal diagnoses that included Intracranial Hemorrhage and Alzheimer's Disease. The patient resided in a SNF. During the record review on 2/9/22 at 11:13 a.m., it was noted that the Hospice POC ordered SN, Aide services, SC and MSW services to be provided. On 2/9/22 at 10:25 a.m., a request was made to the Director of Clinical Services (DCS #1) to receive copies of the above patient's records, including care plans, from the Skilled Nursing Facility (SNF). Upon receipt and review, it was noted that the SNF Plan of Care utilized for the above patients had been generated by the SNF. There was no Hospice Care Plan available for review among the SNF documents. The Hospice Agency failed to ensure that all care and services were provided in accordance with the Hospice Plan of Care. These findings were reviewed with DCS #1 during an interview on 2/9/22 at 2:20 p.m.

Based on record review and interview, it was determined the Hospice failed to identify the care and services that were needed and identify each provider's responsibility for performing the needed functions that had been agreed upon and included in the hospice plan of care in 2 (MR's #9 and 11) of 2 records of patients who resided in a Skilled Nursing Facility, from a total of 13 sampled records reviewed, resulting in the potential for needed care and services to be overlooked and unmet care needs. Findings include: MR #9: This patient was admitted to Hospice on 11/13/21. The period of review was 1/12/22 through 2/10/22 with a terminal diagnosis of Alzheimer's Disease and Covid related Pneumonitis. During a review of the clinical record on 2/8/22 it was noted that the patient resided in a Skilled Nursing Facility (SNF) and was ordered to have Skilled Nursing (SN), Aide services, Spiritual Care (SC) and Medical Social Work (MSW) services to be provided. The patient's Hospice plan of care (POC) did not specify who (Hospice or SNF) would provided the needed services. MR #11: The patient was admitted to Hospice on 2/3/22 with a terminal diagnosis of Intracranial Hemorrhage and Alzheimer's Disease. During the record review on 2/9/22 at 11:13 a.m., it was noted that the patient resided in a SNF and was ordered to have SN, Aide services, SC and MSW services to be provided. The patient's Hospice POC did not specify who (Hospice or SNF) would provided the needed services. On 2/9/22 at 10:25 a.m., a request was made to the Social Worker (MSW #1) to provide copies of the patient's care plans from the SNF. Upon review of the patient's (MR #9 and MR #11) SNF care plans, it was further noted that there was no delineation of duties. It was not clear as to which entity would provide the ordered/needed services. During an interview on 2/9/22 at 11:45, MSW #1 reported, "We make sure we have a contract, like a business agreement. We discuss who will do what at the table." The Hospice failed to identify each provider's/discipline's responsibility. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and the Director of Clinical Services (DCS #1) during an interview on 2/9/22 at 3:07 p.m. and 3:18 p.m.

Based on record review and interview, it was determined that the Hospice failed to ensure the Hospice plan of care reflected the collaborative participation of the Hospice, Skilled Nursing Facility and the patient/family in 2 (MR's #9 and 11) of 2 records reviewed in which the patients resided in a nursing home, resulting in the potential for ineffective coordination of care and unmet care needs. Findings include: MR #9: Nursing home resident, admitted 11/13/21. The period of review was 1/12/22. On 2/8/22 during the review of the patient's Hospice Plan of Care (POC), it was noted that participation by the nursing home staff and patient/family was not reflected in the problems, interventions and documentation of outcomes. MR #11: Nursing home resident, admitted 2/3/22. On 2/9/22 during the review of the patient's Hospice POC, it was noted that participation by the nursing home staff and patient/family was not reflected in the problems, interventions and documentation of outcomes. These findings were reviewed with and acknowledged by the Director of Clinical Services (DCS #1) during an interview on 2/9/22 at 2:20 p.m.

Based on record review and interview, it was determined the Hospice failed to ensure that staff at the Skilled Nursing Facility received orientation and training regarding the Hospice Philosophy and the needs of the Hospice patient, resulting in the potential for unmet care needs for all patients who resided at the Skilled Nursing Facility at the end of life. Findings include: An interview was conducted with the Director of Clinical Services (DCS #1) on 2/9/22 at 12:00 p.m. During the interview, a request was made to review documented evidence that staff at the Skilled Nursing Facility (SNF) received orientation and training on the Hospice Philosophy, policies and procedures for symptom management and the principles of death and dying. On 2/10/22 at 8:53 a.m., DCS #1 submitted a document titled "Hospice Education for Skilled Nursing Facilities" for review. DCS #1 then reported, "The person who does the training never made it to that facility, so no training on the Hospice Philosophy was done." The Hospice failed to ensure orientation and training was provided to the staff of the SNF.