Hospice of Hope

“It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. This standard was not met as evidenced by document review and interview. A review of the agency’s emergency plan revealed that the agency did not ensure that the emergency preparedness plan was updated at least every two years as per the agency’s policy. AGENCY POLICY: The agency’s Emergency Preparedness and Response Plan policy (policy number EC.40, last reviewed on 09/01/2024) stated, in part, that “The Hospice will have a written emergency preparedness and response plan that comprehensively describes identification of potential disasters, including infectious diseases, and its approach to a disaster that could affect the need for its services or ability to provide those services. The plan will... be reviewed and updated, including related policies and procedures, at least every two years.” EMERGENCY MANAGEMENT PLAN: The agency’s Continuity of Operations Business Plan was updated on 03/21/2022. The next documented update of the Continuity of Operations Business Plan was dated on 01/13/2025 (2 years 10 months). During an interview with the Director of Nursing Services (Personnel Record 7) on 05/06/2025, stated that the agency’s emergency plan is updated through the revision of the Continuity of Operations Business Plan. During an interview with the Director of Nursing Services on 05/07/2025, she stated that there was no additional documented evidence of an update to the Continuity of Operations Business Plan between 03/21/2022 and 01/13/2025. A review of the agency’s emergency plan revealed that the agency did not ensure that the emergency preparedness plan was updated at least every two years as per the agency’s policy.”

“It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The hospice EP training program includes the EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years. This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 14 (7%) personnel record reviewed, the agency did not ensure that the staff received education on the agency’s emergency preparedness plan annually as per agency policy. AGENCY POLICY: The agency’s Emergency Preparedness and Response Plan policy (policy number EC.40, last reviewed on 09/01/2024) stated, in part, that “The Hospice will provide initial training at orientation and at least annually thereafter on emergency preparedness policies and procedures to all new and existing staff, contract staff, and volunteers (consistent with their expected role).” PERSONNEL RECORD 14: The personal record for this volunteer, who joined the agency on 09/25/2015 and provided support in the agency’s inpatient unit, included an attestation of completion of New Volunteer Orientation Student Workbook dated on 10/14/2024. The record included no additional documented evidence of education on the agency’s emergency preparedness plan. There was no documented evidence of what was included in the New Volunteer Orientation Student Workbook. During an interview on 05/08/2025 with the Director of Nursing Services (Personnel Record 7), she stated that the New Volunteer Orientation Student Workbook included training on the agency’s emergency preparedness plan. She also stated that she consulted with the Volunteer Coordinator, who stated that there was no additional documented evidence of education on the agency’s emergency preparedness plan.”

“It is required that each patient’s individualized written plan of care include measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. In 5 of 19 (26%) clinical records reviewed revealed the agency did not ensure that the patients’ individualized plans of care included goals that were objectively measurable and individualized for each patient. AGENCY POLICY: The hospice’s policy “Medical Record Content (IM.30)” dated 09/01/2024, stated in part that “...The comprehensive assessment will include data elements that allow for measurement of outcomes to be used in individual patient care planning, coordination of services... the medical record will contain... patient/caregiver goals of care...” The policy entitled, “Plan of Care Process (PC.30)” and dated 09/01/2024 read in part that “... the comprehensive assessment will identify...physical...needs related to the terminal illness that will be addressed to promote the Hospice patient’s...comfort...Data elements that allow for measurement of outcomes...The data elements for each patient will be used in individual patient care planning...” CLINICAL RECORD 5: The patient elected the hospice benefit on 02/07/2025 with the diagnosis of chronic obstructive pulmonary disease (COPD). On 04/11/2025, the Registered Nurse (RN) noted that the patient reported a shortness of breath score of 6 on a scale of 1-10, required oxygen per nasal cannula at three liters continuously, and utilized pursed lip breathing during conversation. The nurse noted on 04/25/2025 that the patient’s respiratory effort was slightly labored and the patient scored his shortness of breath at a 5. There was an identified problem of COPD on the patient’s plan of care, with the goal that the patient would maintain his respiratory baseline as evidenced by breathing at an optimal level within the disease parameters. “Optimal” is not a measurable goal. CLINICAL RECORD 7: The patient elected the hospice benefit on 08/17/2023 with the diagnosis of hypertensive heart disease with heart failure. During the nurse’s visit on 04/29/2025, the patient rated his shortness of breath score as a 7 on a scale of 1-10. The patient’s medication list included: Oxygen 2 liters per minute per nasal cannula continuously as needed for shortness of breath or oxygen saturation readings less than 92%, Albuterol-Ipratropium 2.5mg - 0.5mg/3ml inhalation solution - inhale via nebulizer one vial every four hours as needed for wheezing or dyspnea, and Albuterol-Ipratropium 2.5mg - 0.5mg/3ml inhalation solution - inhale via nebulizer one vial twice a day. There were identified problems of heart failure and hospice care on the patient’s plan of care, with the goals that the patient’s symptoms will be consistent with the stage of the disease process, and problems will be managed as well as the disease process allows. And that the patient and/or family will express satisfactory control of the patient’s symptoms. Symptoms “consistent with stage of disease process” and “managed as well as disease process will allow” are not measurable goals. “Satisfactory control” is also not measurable. CLINICAL RECORD 8: The patient elected the hospice benefit on 11/26/2024 with the diagnosis of malignant neoplasm of the left kidney. On admission, the Registered Nurse (RN) noted that the patient had arthritis, a spinal compression fracture, and malignancy-related pain. The patient’s medication profile included Oxycodone 5mg tablet - take half a tablet (2.5mg) by mouth every four hours as needed for moderate pain or shortness of breath. The problem of cancer was identified in the patient’s plan of care with the goal that the patient and/or caregiver will demonstrate an understanding of the appropriate use of medications for pain and symptom management. There was no measurable goal for the patient’s pain. CLINICAL RECORD 10: The patient elected the hospice benefit on 05/28/2023. On admission, the nurse identified the problems of pain management and anxiety. The patient’s medication profile included Ativan 0.5mg tablet - 2 tablets (1 mg) by mouth at bedtime, Ativan 0.5mg tablet - 1 tablet (0.5mg) by mouth four times a day as needed for anxiety, Dilaudid 4mg oral tablet - 1 tablet (4mg) by mouth four times a day as needed for pain or shortness of breath, Quetiapine 100mg tablet - 1 tablet (100mg) by mouth twice a day, and Quetiapine 300mg tablet - 1 tablet (300mg) by mouth at bedtime. The symptom assessment flowsheet for 02/01/2025 included a pain score of 8 and an anxiety score of 8. On 03/10/2025, the patient’s pain score was a 9. On 04/23/2025, the nurse documented the patient’s neck pain as a 6 on a scale of 1-10. The pain management problem was identified in the plan of care. The goal was that the patient would be free from pain or verbalize an acceptable level of pain with the current pain management regimen, and that the patient and/or family would express satisfactory control of symptoms. “Acceptable level” and “satisfactory control of symptoms” are not measurable goals. Anxiety was also an identified problem. The goal was that the patient and/or caregiver would verbalize relief from anxiety. “Relief” is not a measurable goal. CLINICAL RECORD 11: The patient elected the hospice benefit on 02/07/2025 with the diagnosis of Parkinson’s. The Physician’s Certification of Terminal Illness for the benefit period 02/07/2025 to 05/07/2025 included a related diagnosis of constipation. The patient’s medication list included: Fleet enema 7g/19g rectal enema once daily as needed for constipation, Bisacodyl 10mg suppository per rectum three times a week, and Bisacodyl 5mg oral delayed release tablet once a day as needed for constipation. Constipation was an identified problem on the patient’s plan of care, with the goal that the patient would demonstrate decreased signs and symptoms of constipation. “Decreased” is not a measurable goal. It was confirmed that the goals in evidence were not measurable during an interview with the Patient Care Coordinator on 05/08/2025.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review, document review and interview. In 12 of 19 (63%) Clinical records reviewed revealed that the agency did not ensure that the individualized care plan was reviewed, revised, or updated no less frequently than every 15 calendar days. AGENCY POLICY: The hospice’s policy “Timelines (AR.14—Addendum)” dated 10/03/2024 reads in part: “Physician signatures are obtained on the IDT Plan of Care at the Interdisciplinary Meeting...All medical record information will be incorporated into the patient’s medical record within 7 business days of providing service...” CLINICAL RECORD 1: The patient elected the hospice benefit on 11/05/2024. At the time of clinical record review, the Interdisciplinary Group Meetings held on 04/16/2025 and 04/30/2025 were not documented in the clinical record. There was no documented evidence of updates to the plan of care. CLINICAL RECORD 11: The patient elected the hospice benefit on 02/07/2025. At the time of clinical record review, the Interdisciplinary Group Meetings held on 04/16/2025 and 04/30/2025 were not documented in the clinical record. There was no documented evidence of updates to the plan of care. CLINICAL RECORD 12: The patient elected the hospice benefit on 01/25/2025. At the time of clinical record review, the Interdisciplinary Group Meetings held on 04/16/2025 and 04/30/2025 were not documented in the clinical record. There was no documented evidence of updates to the plan of care. CLINICAL RECORD 2: The patient elected the hospice benefit on 02/28/2025. At the time of clinical record review, the Interdisciplinary Group Meetings held on 04/16/2025 and 04/30/2025 were not documented in the clinical record. There was no documented evidence of updates to the plan of care. CLINICAL RECORD 3: The patient elected the hospice benefit on 03/27/2025. At the time of clinical record review, the Interdisciplinary Group Meetings held on 04/16/2025 and 04/30/2025 were not documented in the clinical record. There was no documented evidence of updates to the plan of care. CLINICAL RECORD 4: The patient elected the hospice benefit on 03/13/2025. At the time of clinical record review, the Interdisciplinary Group Meetings held on 04/16/2025 and 04/30/2025 were not documented in the clinical record. There was no documented evidence of updates to the plan of care. CLINICAL RECORD 13: The patient elected the hospice benefit on 03/27/2025. At the time of clinical record review, the Interdisciplinary Group Meetings held on 04/16/2025 and 04/30/2025 were not documented in the clinical record. There was no documented evidence of updates to the plan of care. CLINICAL RECORD 5: The patient elected the hospice benefit on 02/07/2025. At the time of clinical record review, the Interdisciplinary Group Meetings held on 04/16/2025 and 04/30/2025 were not documented in the clinical record. There was no documented evidence of updates to the plan of care. CLINICAL RECORD 7: The patient elected the hospice benefit on 08/17/2023. At the time of clinical record review, the Interdisciplinary Group Meetings held on 04/16/2025 and 04/30/2025 were not documented in the clinical record. There was no documented evidence of updates to the plan of care. CLINICAL RECORD 9: The patient elected the hospice benefit on 10/01/2024. At the time of clinical record review, the Interdisciplinary Group Meetings held on 04/16/2025 and 04/30/2025 were not documented in the clinical record. There was no documented evidence of updates to the plan of care. CLINICAL RECORD 8: The patient elected the hospice benefit on 11/26/2024. At the time of clinical record review, the Interdisciplinary Group Meetings held on 04/16/2025 and 04/30/2025 were not documented in the clinical record. There was no documented evidence of updates to the plan of care. CLINICAL RECORD 10: The patient elected the hospice benefit on 05/08/2023. At the time of clinical record review, the Interdisciplinary Group Meetings held on 04/16/2025 and 04/30/2025 were not documented in the clinical record. There was no documented evidence of updates to the plan of care. During an interview and joint clinical record review on 05/07/2025 with the Patient Care Coordinator, it was confirmed that the Interdisciplinary Group Meetings for 04/16/2025 and 04/30/2025 were not documented in the patient’s clinical record at the time of clinical record review.”

“It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by document review, observation, and personnel record review. In 1 of 10 (100%) personnel record reviewed revealed the agency did not ensure that employees received education on infection control annually as per agency policy. AGENCY POLICY: The agency’s Exposure Control Plan policy (policy number IC.5, last reviewed on 05/01/2025) stated, in part, “Hospice Responsibilities: To provide training and information related to airborne and bloodborne pathogens for all HCP [Healthcare Personnel] upon hire and annually thereafter”. It also stated, in part, that “Healthcare Personnel refers to all paid and unpaid persons serving in healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials.” PERSONNEL RECORD 10: A review of the volunteer’s personnel record with a date of hire 09/25/2024 and provided support in the agency’s inpatient unit, contained an attestation of completion of New Volunteer Orientation Student Workbook dated on 10/14/2024. The personnel record contained no additional documented evidence of education on infection control. During an interview on 05/08/2025 with the Director of Nursing Services (Personnel Record 7), stated that the New Volunteer Orientation Student Workbook contained training on infection control. She also stated that she consulted with the Volunteer Coordinator, who stated that there was no additional documented evidence of education on infection control during the survey focus period.”

“It is required the bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review, document review, and interview. In 2 of 2 (100%) clinical records in which bereavement services were accepted revealed the agency did not ensure that a bereavement plan of care was developed. AGENCY POLICY: The policy entitled, “Bereavement (PC.130)” and dated 11/01/2021 included in part that “...After the death of the patient, the Bereavement Coordinator will complete a follow-up assessment and develop a POC for the bereavement services based on the re-assessment and the family and/or caregiver’s willingness to receive services. This POC will be discussed at the next IDG/IDT meeting...The bereavement POC will include delineation of services and frequency to be provided, which may include...individual bereavement counseling, support groups, telephone calls, memorial services, cards, letters, mailings, and referrals to community services as appropriate...” CLINICAL RECORD 17 : The patient elected the hospice benefit on 03/22/2024 and died on hospice services on 12/31/2024. The post-death assessment and the Interdisciplinary Group Meeting (IDG) on 01/02/2024 included a bereavement risk level. The clinical record was missing a bereavement plan of care, and there it did not contain interventions with the expected frequency and timelines for those interventions. The medical social worker (MSW) bereavement communication note dated 01/13/2025 documented contact with the patient’s spouse and that spouse was informed re: bereavement program - including mail outs about grief, invitations to support groups. Emotional support offered. There was no documented evidence that a bereavement plan of care was developed. CLINICAL RECORD 19: The patient elected the hospice benefit on 01/14/2025 and died on hospice services on 04/12/2025. The post-death assessment on 04/24/2025 was conducted by the MSW. There was no post-death IDG documented in the medical record at the time of record review. There was no documented evidence of a bereavement plan of care developed to include interventions with the expected frequency and timelines for those interventions. During a joint clinical record review and interview with the Patient Care Coordinator on 05/08/2025, she confirmed that neither clinical record documented bereavement plan of care planning, interventions, and frequencies.”

“It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. In 3 of 7 (43%) clinical records reviewed for patients receiving hospice aide services revealed that the agency did not ensure that the hospice aide completed all interventions on the patient’s care plan. AGENCY POLICY: The agency’s policy, entitled “Implementing Care and Treatment (PC.35),” and dated 09/01/2024, read in part that “...The hospice aide (HA) will be provided with written instructions for patient care prepared by a Registered Nurse (RN), which may include...personal care...Reporting changes in the patient’s medical, nursing, rehabilitative, and or social conditions/needs to a Registered Nurse as the changes relate to the POC...Completing appropriate documentation...” CLINICAL RECORD 5: The patient elected the hospice benefit on 02/07/2025. The plan of care for the benefit period 02/07/2025 to 05/07/2025 included orders for the hospice aide to visit the patient three times a week. The hospice aide’s plan of care dated 02/07/2025 included bathing the patient via a shower chair, providing oral, denture, foot, skin, perineal, and nail care, shaving the patient with a safety razor, recording the patient’s last bowel movement, and measuring and recording the patient’s blood pressure, respiratory rate, and pulse rate, and assisting the patient to dress. During the hospice aide visit on 04/09/2025, the aide noted that the interventions for oral care, denture care, shaving with a safety razor, and shampooing the patient’s hair were performed. There was no documented evidence that the aide performed the ordered bath, perineal care, foot care, nail care, shaving, recording of vital signs and last bowel movement. On 04/18/2025 visit, the aide did not document that the patient’s blood pressure, pulse, respirations, or oral or denture care tasks were completed during the visit. On 04/25/2025, the aide noted that the respiratory rate, blood pressure, or pulse were not obtained. Neither were the interventions for oral and denture care, nor was the patient shaved with a safety razor. During the aide visit on 04/30/2025, the aide documented that she did not complete the oral and denture care interventions, shaving the patient with a safety razor, or shampooing the patient. CLINICAL RECORD 8: The patient elected the hospice benefit on 11/26/2024. The plan of care for the benefit period 02/24/2025 to 05/24/2025 included orders for the hospice aide to visit the patient three times a week. The hospice aide’s plan of care dated 11/26/2024 included assisting the patient to the bedside commode, providing oral, perineal, skin, and nail care, measuring and recording the patient’s blood pressure, respiration, and pulse rate, providing a bath via a shower chair, and assisting the patient with dressing. During the visit by the hospice aide on 03/28/2025, the hospice aide noted that she had not obtained and recorded the patient’s blood pressure, respiratory rate, or pulse rate. On 04/02/2025 and 04/09/2025, the hospice aide marked the patient’s shampoo as incomplete. The hospice aide marked that the patient refused to have her hair shampooed and that oral care was not provided on the visit for 04/11/2025 CLINICAL RECORD 12: The patient elected the hospice benefit on 01/25/2025. The plan of care for the benefit period 01/25/2025 to 04/24/2025 included orders for the hospice aide to visit the patient five times a week. The hospice aide’s plan of care dated 01/25/2025 included providing catheter care, bathing the patient via shower chair or bed bath, providing oral and perineal care, shampooing, and shaving the patient with a safety razor. During the visits on 04/02/2025, 04/09/2025, 04/16/2025, and 04/23/2025, the hospice aide documented that she had not performed the interventions to shampoo the patient, provide oral care, or shave with a safety razor. During a joint clinical record review and interview with the Patient Care Coordinator on 05/07/2025, she confirmed that, unless otherwise documented, the interventions in the hospice aide care plan are expected to be performed at each aide visit. Additionally, she confirmed that the aide did not complete all interventions as written by the Registered Nurse (RN) in the plan of care.”

“It is required that hospice aides must report changes in the patient’s nursing needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review, document review, and interview. In 3 of 7 (43%) clinical records reviewed for patients receiving hospice aide services revealed that the agency did not ensure that the hospice aide reported changes related to the plan of care to the Registered Nurse (RN) in accordance with agency policy. AGENCY POLICY: The agency’s policy entitled “Implementing Care and Treatment (PC.35),” and dated 09/01/2024, read in part that “...The hospice aide (HA) will be provided with written instructions for patient care prepared by a Registered Nurse (RN), which may include...personal care...Reporting changes in the patient’s medical, nursing, rehabilitative, and or social conditions/needs to a Registered Nurse as the changes relate to the POC...Completing appropriate documentation...” CLINICAL RECORD 5: The patient elected the hospice benefit on 02/07/2025. The plan of care for the benefit period 02/07/2025 to 05/07/2025 included orders for the hospice aide to visit the patient three times a week. The hospice aide’s plan of care dated 02/07/2025 included bathing the patient via a shower chair, providing oral, denture, foot, skin, perineal, and nail care, shaving the patient with a safety razor, recording the patient’s last bowel movement, and measuring and recording the patient’s blood pressure, respiratory rate, and pulse rate, and assisting the patient to dress. During the hospice aide visit on 04/09/2025, the aide noted that the interventions for oral care, denture care, shaving with a safety razor, and shampooing the patient’s hair were performed. There was no documented evidence that the aide performed the ordered bath, perineal care, foot care, nail care, shaving, recording of vital signs and last bowel movement. On 04/18/2025 visit, the aide did not document that the patient’s blood pressure, pulse, respirations, or oral or denture care tasks were completed during the visit. On 04/25/2025, the aide noted that the respiratory rate, blood pressure, or pulse were not obtained. Neither were the interventions for oral and denture care, nor was the patient shaved with a safety razor. During the aide visit on 04/30/2025, the aide documented that she did not complete the oral and denture care interventions, shaving the patient with a safety razor, or shampooing the patient. There was no documented evidence that the RN was notified that the plan of care interventions were not completed in accordance with agency policy. CLINICAL RECORD 8: The patient elected the hospice benefit on 11/26/2024. The plan of care for the benefit period 02/24/2025 to 05/24/2025 included orders for the hospice aide to visit the patient three times a week. The hospice aide’s plan of care dated 11/26/2024 included assisting the patient to the bedside commode, providing oral, perineal, skin, and nail care, measuring and recording the patient’s blood pressure, respiration, and pulse rate, providing a bath via a shower chair, and assisting the patient with dressing. During the visit by the hospice aide on 03/28/2025, the hospice aide noted that she had not obtained and recorded the patient’s blood pressure, respiratory rate, or pulse rate. On 04/02/2025 and 04/09/2025, the hospice aide marked the patient’s shampoo as incomplete. The hospice aide noted that the patient refused to have her hair shampooed and that oral care was not provided during the visit on 04/11/2025. There was no documented evidence that the RN was notified that the plan of care interventions were not completed in accordance with agency policy. CLINICAL RECORD 12: The patient elected the hospice benefit on 01/25/2025. The plan of care for the benefit period 01/25/2025 to 04/24/2025 included orders for the hospice aide to visit the patient five times a week. The hospice aide’s plan of care dated 01/25/2025 included providing catheter care, bathing the patient via shower chair or bed bath, providing oral and perineal care, shampooing, and shaving the patient with a safety razor. During the visits on 04/02/2025, 04/09/2025, 04/16/2025, and 04/23/2025, the hospice aide documented that she had not performed the interventions to shampoo the patient, provide oral care, or shave with a safety razor. There was no documented evidence that the RN was notified that the plan of care interventions were not completed in accordance with agency policy. During a joint clinical record review and interview with the Patient Care Coordinator on 05/07/2025, she confirmed that, unless otherwise documented, the interventions in the hospice aide care plan are expected to be performed at each aide visit. Additionally, she confirmed that the aide did not complete all interventions as written by the Registered Nurse (RN) in the plan of care or document notification of the RN.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. Each patient’s record includes physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed revealed the agency did not ensure there were documented physician orders for care provided. AGENCY POLICY: The agency’s policy “Medical Record Content (IM.30)”, dated 09/01/2024, reads in part that “...The content of the medical record will include...physician orders.” The hospice’s policy “Timelines (IM.40)” dated 09/01/2024 included in part that “...Supplemental verbal orders may be obtained before care is provided and are written within 24 hours of receiving the orders...” The policy entitled “Timelines - Addendum (AR.14)” and dated 10/03/2024 included in part that “...All medical record information will be incorporated into the patient’s medical record within 7 business days of providing service...” CLINICAL RECORD 7: The patient elected the hospice benefit on 08/17/2023. During the Registered Nurse (RN) visit on 06/28/2024, a new stage two pressure ulcer to the upper back/scapula area was identified measuring 2.5cm x 2cm x 0.1cm that was cleaned with normal saline and covered with a Duoderm, per the nurse’s note. The wound was still active as of the nurse’s note on 04/15/2025 measuring 2.2cm x 1.8cm x 0.1cm. A physician’s order was documented on 11/15/2024 for the wound to be cleansed with normal saline and apply a foam border dressing every three days and if the dressing became soiled or dislodged. There was no wound care orders documented from 06/28/2024 to 11/14/2024 and no plan of care for the wound. During a joint clinical record review and interview with the Patient Care Coordinator on 05/08/2025, she confirmed a gap in wound care orders from 06/28/2024 to 11/14/2024.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident: the most recent hospice plan of care for each patient/resident. This standard was not met as evidenced by clinical record review, document review, interview, and observation. In 1 of 1 (100%) home visit performed at a nursing facility revealed the agency did not ensure that the facility was provided with the hospice plan of care or any plan of care updates. AGENCY POLICY: The agency’s policy “Hospice Care in a SNF/NF or ICF/IID (PC.125),” dated 11/22/2024, states in part that “...The Hospice will provide the facility with... The most recent Hospice POC specific to each patient...” Addendum (to IM.40) “Timelines” 10/03/2024 “...All medical record information will be incorporated into the patient’s medical record within 7 business days of providing service...” HOME VISIT 3: The patient, who resided at a Nursing Facility/long-term Care Facility, elected the hospice benefit on 03/27/2025. During the home visit with the Registered Nurse (RN)(Personnel Record 3) on 05/07/2025, a review of the hospice’s facility chart revealed that there were no Initial Plan of Care (POC) or POC Updates. At the time of clinical record review on 05/07/2025, the patient’s clinical record contained a documented Interdisciplinary Group (IDG) Meeting on 04/02/2025. There was no documented evidence of IDG meetings in the clinical record after that date. The IDG 4/2/25 included LOC, location, dx, meds, CP all disciplines, admission orders/orders for care/discipline orders - signed by IDG 4/2/25 (RN, MD, MSW, NP, CH). The Initial Plan of Care for the benefit period 03/27/2025 to 06/24/2025 was signed by the hospice RN on 04/16/2025 and by the hospice physician on 04/30/2025. During an interview with the Patient Care Coordinator on 05/07/2025, she could not provide me with any documentation showing that the plan of care or any updated plans of care were provided to the nursing facility.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IID with the physician certification and recertification of the terminal illness for each patient/resident. This standard was not met as evidenced by document review, interview, and observation. In 1 of 1 (100%) home visit performed at a nursing facility revealed the agency did not ensure that the facility was provided with the physician certification and recertification of terminal illness for each patient. AGENCY POLICY: The agency’s policy “Hospice Care in a SNF/NF or ICF/IID (PC.125),” dated 11/22/2024, states in part that “...The Hospice will provide the facility with... The physician certification and recertification of the terminal illness specific to each patient...” HOME VISIT 3: The patient, who resided at a Nursing Facility/long-term Care Facility, elected the hospice benefit on 03/27/2025. During Home Visit 3 observation with the Registered Nurse (RN) (Personnel Record 3) on 05/07/2025, a review of the hospice’s facility chart revealed no Initial Physician’s Certification of Terminal Illness (CTI). During the clinical record (Clinical Record 3) review, it was identified that the Initial CTI for the benefit period 03/27/2025 to 06/24/2025 included a narrative by the hospice physician dated 04/25/2025 with the doctor’s signature dated 04/30/2025. There was a verbal certification documented 03/27/2025 on a paper form “Prospective Client Data” with the physician’s name, the date of the verbal certification, and the signature of the nurse receiving the certification, also dated 03/27/2025. None of this documentation was present in the facility’s hospice documentation. During an interview with the Patient Care Coordinator on 05/07/2025, she stated that the hospice agency does not provide the physician’s certification/recertification of terminal illness to the facility. She questioned if it was required to provide the SNF/NF the CTI or best practice, so this site visitor supplied the regulatory verbiage.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IID with the hospice medication information for each patient/resident. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 1 (100%) home visit performed at a nursing facility revealed the agency did not ensure that the hospice and facility medication profiles included the same medications. AGENCY POLICY: The agency’s policy “Hospice Care in a SNF/NF or ICF/IID (PC.125),” dated 11/22/2024, states in part that “...The Hospice responsibilities will include...Medical direction and management of the patient...The POC will be written in collaboration with the Interdisciplinary Group/Team (IDG/IDT), facility staff, patient, and/or the family...The Hospice will provide the facility with...The hospice medication information specific to each patient...” HOME VISIT 3: The patient, who resided in a nursing facility, elected the hospice benefit on 03/27/2025. The patient’s medication profile included Gabapentin oral 100mg tablet - 100mg by mouth every night at bedtime, and the order was dated 03/27/2025. During the home visit observation of the Registered Nurse (RN) on 05/07/2025, this site visitor requested a copy of the facility’s medication profile for the patient, which the facility nurse provided. In comparing the two medication lists, the facility’s medication list did not include the hospice’s Gabapentin order. The RN was interviewed on 05/07/2025. She stated that she was unaware that the Gabapentin was not on the facility list. I requested that she double-check the facility’s order summary report (that included active orders as of 05/07/2025), and she confirmed that the medication was not listed on the facility’s medication record for the patient. Upon return to the office, the RN contacted the patient’s daughter regarding the discrepancy and inquired if the patient’s daughter wished for the patient to receive the medication, and she did not. The hospice RN stated she would contact the hospice Medical Director for orders to discontinue the drug from the hospice’s medication profile. During an interview with the Patient Care Coordinator on 05/07/2025, she provided documentation that the initial hospice medication profile was faxed to the nursing facility upon admission on 03/27/2025. In addition, she agreed that despite the faxed medication list, the hospice did not follow up to ensure that the patient’s medication list at the hospice and the nursing facility included all the same medications.”