Pec Hospice

“Based on observation, interview, and record review, the hospice failed to ensure care and services were provided in accordance with the POC for two of two sampled patients (Patients 1 and 2). This failure had the potential risk of not providing appropriate, consistent, and quality care to these patients.Findings: Review of the hospice’s P&P titled The Plan of Care revised April 2020 showed a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted in the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The procedure includes the plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs. Review of the hospice’s P&P titled Missed Visit revised 4/2020 showed missed visit will be communicated to the Interdisciplinary Group at the IDG Meeting. Missed visit will be documented in the clinical record. If a visit is missed for any reason, the clinician should attempt to reschedule for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. If a visit is missed and not rescheduled, the clinician will notify the IDG and clinical supervisor of the missed visit. If an aide visit is missed the aide will contact the case manager or clinical supervisor and the manager/supervisor will take the appropriate measures stated above. 1. Review of Patient 1’s clinical record was initiated on 9/18/25. The clinical record showed the SOC was on 6/9/25. The patient was certified for hospice services during the certification periods from 6/12/25 to 8/10/25 and 8/11/25 to 10/9/25. The POC/IDG Review, for the certification periods from 6/12/25 to 8/10/25 and 8/11/25 to 10/9/25, showed HA visit two times per week for assistance with ADL and personal cares. However, review of the HA Visit Notes showed there was no documented evidence of a HA visit for the weeks of 6/9/25 to 6/14/25 and 8/3/25 to 8/9/25. In addition, for the weeks of 6/15/25 to 6/21/25 and 8/31/25 to 9/6/25, there was only one HA visit a week instead of two visits a week as ordered in the POC. The POC/IDG Reviews dated 6/18, 7/2, 7/16, 7/30, 8/13, 8/27, and 9/10/25, showed SN visit once per week and two PRN visits for changes in condition and symptom management. However, review of the SN Visit Notes showed there was documented evidence of the SN visits for the weeks of 6/15/25 to 6/21/25 and 9/7/25 to 9/13/25. Further review of the clinical record failed to show documented evidence of an attempt to reschedule the visit within the same week as per the hospice’s P&P. On 9/23/25 at 1057 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee. The DPCS/Administrator Designee was informed and acknowledged the findings. 2. Review of Patient 2’s clinical record was initiated on 9/18/25. The clinical record showed the SOC was on 6/19/25. The patient was certified for hospice services during the certification periods from 7/6/25 to 9/3/25 and 9/4/25 to 11/2/25. a. The POC/IDG Review dated 9/10/25, showed in the nursing section, a new wound care treatment to Stage 4 sacrococcygeal pressure injury dated 9/2/25, as follows: to cleanse wound with normal saline, pat peri wound dry with a 4x4 gauze, apply a thin layer of topical Bactroban (antibiotic) ointment on wound bed, apply a thin layer of calmoseptine (moisture barrier) to peri wound, and cover wound bed with a 4x4 bordered foam dressing three times per week for 14 days. A joint home visit with LVN 1 was conducted on 9/19/25 at 0855 hours, to Patient 2’s home. LVN 1 was observed performing a head-to-toe assessment and providing wound treatment. During the wound treatment to the patient’s pressure injury wound to the sacral area, LVN 1 removed the old dressing, assessed, and took a picture of the patient’s wound. Then, LVN 1 sprayed the wound with a wound cleanser, patted the wound dry with a 4x4 gauze, applied barrier moisture ointment, and covered the wound with a foam dressing. On 9/19/25 at 1208 hours, an interview and concurrent clinical record review was conducted with LVN 1. LVN 1 verified he applied barrier moisture ointment and stated it was an equivalent ointment for hydrogel ointment (used to facilitate debridement in wounds with necrotic and slough tissues). LVN 1 showed a documentation of a physician’s wound treatment order dated 8/7/25, to cleanse Stage 2 pressure injury to sacral area with mild cleanser, pat dry, apply hydrogel, and cover with a border dressing. On 9/23/25 at 1221 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee. The DPCS/Administrator Designee reviewed the physician’s wound treatment order for the patient and verified LVN 1 did not follow the new treatment wound order dated 9/2/25, and POC. The DPCS/Administrator Designee was informed and acknowledged the finding. b. The POC/IDG Review for the certification periods of 7/6/25 to 9/3/25 and 9/4/25 to 11/2/25, included an intervention under the Integumentary/Skin section for the SN to assess changes in wound status which included to check the size, integrity, location, type/stage, signs and symptoms of infection, drainage, and effectiveness of current treatment. However, review of the LVN Visit Notes dated 7/10, 8/7, 8/19, 9/4, and 9/11/25, failed to show documented evidence of a wound assessment as per the POC. On 9/23/25 at 1309 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee. The DPCS/Administrator Designee verified there was no documented evidence the LVN completed a wound assessment. The DPCS/Administrator Designee was informed and acknowledged the finding. Cross reference to L651, example b.”

“Based on interview and record review, the hospice failed to ensure individualized care plans were developed for two of two sampled patients (Patients 1 and 2). This failure had the potential risk to cause an inconsistent delivery of care which can result in the decline or lack of improvement of the patients’ health conditions.Findings: Review of the hospice’s P&P titled The Plan of Care revised April 2020 showed a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted in the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The procedure includes the plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs 1. Review of Patient 1’s clinical record was initiated on 9/18/25. The clinical record showed the SOC was on 6/9/25. The patient was certified for hospice services during the certification periods from 6/12/25 to 8/10/25 and 8/11/25 to 10/9/25. Review of the Psychosocial Assessment dated 9/13/25, showed the MSW conducted a visit. The narrative notes showed the MSW recommended continuation of current palliative care measures with close monitoring for changes in the patient’s condition and planned to visit the patient once per the recertification period and as necessary. However, review of the POC/IDG Reviews dated 6/18, 7/2, 7/16, 7/30, 8/13 and 8/27/25, failed to show documented evidence a psychosocial care plan was developed to address the MSW assessment. On 9/23/25 at 1111 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee. The DPCS/Administrator Designee was informed and acknowledged the finding. 2. Review of Patient 2’s clinical record was initiated on 9/18/25. The clinical record showed the SOC was on 6/19/25. The patient was certified for hospice services during the certification periods from 7/6/25 to 9/3/25 and 9/4/25 to 11/2/25. a. Review of the Psychosocial Assessment dated 6/24/25, showed the MSW conducted a visit. The narrative notes showed the MSW would maintain periodic contact with the patient and PCG to monitor the patient’s health, emotional well-being, and care needs; and planned to visit the patient once per the recertification period and additionally as required. However, review of the POC/IDG Reviews dated 7/16, 7/30, 8/13, 8/27, and 9/10/25, failed to show documented evidence a psychosocial care plan was developed to address the MSW assessment. On 9/23/25 at 1141 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee. The DPCS/Administrator Designee was informed and acknowledged the finding. b. Review of the POC/IDG Review dated 8/27/25, showed in the nursing section, new symptoms/updates: on 8/25/25, the discoloration was noted on the patient’s bilateral hands during the RN’s visit. However, there was no documented evidence a plan of care was developed to address the patient’s bilateral hands discoloration. On 9/23/25 at 1225 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee. The DPCS/Administrator Designee was informed and acknowledged the finding.”

“Based on interview and record review, the hospice failed to ensure the IDG had reviewed/revised the patients’ POCs no less frequently than every 15 calendar days for two of two sampled patients (Patients 1 and 2). This failure had the potential risk for not providing appropriate, consistent, and quality care to Patients 1 and 2.Findings: Review of the hospice’s P&P titled the Plan of Care revised April 2020 showed the plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the IDG and will be reviewed on a regular basis but no less than every fifteen (15) days. 1. Review of Patient 1’s clinical record was initiated on 9/18/25. The clinical record showed the SOC was on 6/9/25. The patient was certified for hospice services during the certification periods from 6/12/25 to 8/10/25 and 8/11/25 to 10/9/25.The physician’s orders showed the following frequency of visits:- Dated 6/9/25, HA visits two times per week for assistance with ADLs and personal care.- Dated 6/13/25, MSW visit once every recertification period and as needed for psychosocial support. The POC/IDG Review dated 6/18, 7/2, 7/16, 7/30, 7/30, 8/13, 8/27, and 9/10/25, in the section of Frequency of Visits, showed HA visit once per week for assistance with ADL and personal care and MSW one visit for initial assessment. However, the section of the Frequency of Visit was not revised to reflect the HA and MSW visits as per the physician’s order. On 9/23/25 at 1124 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee. The DPCS/Administrator Designee stated the HA visit frequency was incorrect and should be two times per week. The DPCS/Administrator stated the MSW frequency visit order and recommendations should be reflected in the POC/IDG Review. The DPCS/Administrator Designee was informed and acknowledged the findings. 2. Review of Patient 2’s clinical record was initiated on 9/18/25. The clinical record showed the SOC was on 6/19/25. The patient was certified for hospice services during the certification periods from 7/6/25 to 9/3/25 and 9/4/25 to 11/2/25. a. The POC/IDG Review dated 7/16/25, showed a physician’s order dated 7/2/25, for HA to visit the patient two times per week for assistance with ADLs and personal care. In the section of the Frequency of Visit, showed HA visit three times per week for assistance with ADLs and personal care. However, the section of the Frequency of Visit was not revised to reflect the physician’s order of HA frequency visit. On 9/23/25 at 1134 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee. The DPCS/Administrator Designee stated the HA visit frequency was incorrect and should be changed to two times per week because the patient had a private caregiver. The DPCS/Administrator stated the section in the frequency visit should have reflected HA visits two times per week instead of three times per week. The DPCS/Administrator Designee was informed and acknowledged the finding. b. The POC/IDG Review dated 9/10/25, showed a physician’s order dated 9/2/25, to cleanse stage 4 sacrococcygeal pressure injury wound with normal saline, pat peri wound dry with a 4x4 gauze, apply a thin layer of topical Bactroban ointment on wound bed, apply a thin layer of calmoseptine to peri wound, and cover wound bed with a 4x4 bordered foam dressing three times per week for 14 days. However, in the Integumentary/Skin section, the intervention showed for stage 2 sacrococcygeal pressure injury to cleanse the wound with normal saline, pat peri-wound area dry with 4x4 gauze as ordered, apply Medihoney (antibacterial honey-based dressing) to the wound bed, cover with 4x4 bordered foam dressing every two days or as needed if soiled or non-adherent. *The POC did not reflect the new wound treatment for the patient’s sacrococcygeal pressure injury wound. On 9/23/25 at 1227 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee. The DPCS/Administrator Designee stated the new wound treatment order to the patient’s sacrococcygeal pressure injury should had been reflected in the POC and the staging for the new wound treatment order should be stage 4 and not stage 2. The DPCS/Administrator Designee was informed and acknowledged the finding.”

“Based on interview and record review, the hospice failed to ensure the IDG maintained the responsibility for directing, coordinating, and supervising the care and services provided for two of two sampled patients (Patients 1 and 2). This failure had the potential risk of not addressing the care needs for these patients. Findings: Review of the hospice’s P&P titled IDG Coordination of Care revised April 2020 showed the hospice will utilize a case management system to guide an IDG to provide comprehensive, coordinated hospice care to patients and family/caregivers. It will be the responsibility of the Clinical Supervisor/Nursing Supervisor to assign a Case Manager who is a RN. The Case Manager will be responsible for coordination of services with the IDG from referral to discharge. The type and scope of services provided by the IDG will be based upon the comprehensive and ongoing assessment regarding the needs of the patient and the family/caregiver and the comprehensive plan of care that defines patient and family/caregiver problems, goals, and interventions. The IDG will maintain responsibility for the provision and coordination of care, regardless of the setting where care is provided to its patients. Review of the hospice’s P&P titled Missed Visit revised 4/2020 showed missed visit will be communicated to the Interdisciplinary Group at the IDG Meeting. Missed visit will be documented in the clinical record. If a visit is missed for any reason, the clinician should attempt to reschedule for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. If a visit is missed and not rescheduled the clinician will notify the IDG and the clinical supervisor of the missed visit. If an aide visit is missed the aide will contact the case manager or clinical supervisor and the manager/supervisor will take the appropriate measures stated above. 1. Review of Patient 1’s clinical records showed the HA and SN did not conduct the visits as cited in the POC. Cross reference to L543, example 1.However, there was no documented evidence of IDG notification regarding the missed visits as per the hospice’s P&P. There was no documented evidence of an IDG discussion regarding the missed visits during the IDG meetings for Patient 1. The IDG failed to maintain the responsibility for supervising the care and services provided to Patient 1. On 9/23/25 at 1057 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee. The DPCS/Administrator Designee stated there should be a documented communication for the missed visit to a patient. The DPCS/Administrator Designee stated the missed visit should be discussed and coordinated with the physician and IDG. The DPCS/Administrator Designee was informed and acknowledged the finding. 2. Review of Patient 2’s clinical record was initiated on 9/18/25. The clinical record showed the SOC was on 6/19/25. The patient was certified for hospice services during the certification periods from 7/6/25 to 9/3/25 and 9/4/25 to 11/2/25. The POC/IDG Review dated 9/10/25, showed a physician’s order dated 9/2/25, to cleanse Stage 4 sacrococcygeal pressure injury wound with normal saline, pat peri wound dry with a 4x4 gauze, apply a thin layer of topical Bactroban ointment on wound bed, apply a thin layer of calmoseptine to peri wound, and cover wound bed with a 4x4 bordered foam dressing 3 times per week for 14 days. However, the intervention showed for Stage 2 sacrococcygeal pressure injury, to cleanse the wound with normal saline, pat peri-wound area dry with 4x4 gauze as ordered, apply Medihoney to the wound bed, cover with a 4x4 bordered foam dressing every two days or as needed if soiled or non-adherent. The Wound Progress Report from the Wound Specialist visits dated 9/9 and 9/16/25, showed Stage 2 pressure injury to sacroccocyx wound treatment order was to cleanse the wound with normal saline, pat the peri-wound dry with a 4x4 gauze, apply thin layer of hydrogel ointment on the wound, apply thin layer of calmoseptine to peri-wound, and cover the wound bed with a 4x4 bordered foam dressing three times a week for 14 days. However, there was no documented evidence of communication or coordination with the IDG and physician on the updated wound treatment orders for the patient’s Stage 2 sacrococcyx pressure injury. On 9/23/25 at 1259 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee. The DPCS/Administrator Designee stated if the Wound Specialist had an immediate change in wound treatment orders, the Wound Specialist would email the treatment order to the hospice. The DPCS/Administrator Designee stated the Wound Specialist would send their visit wound progress report within two days of the visit date. The DPCS/Administrator Designee verified the Wound Specialist wound treatment orders for the patient’s Stage 2 pressure injury to the sacrococcyx was not coordinated in the IDG meeting to update the treatment orders or reflect on the POC so the disciplines could follow the most updated order from the Wound Specialist. The DPCS/Administrator Designee was informed and acknowledged the finding.”

“Based on interview and record review, the hospice Administrator failed to be responsible for the day-to-day operations of the organization and maintain the administrative and supervisory responsibility for all care provided as evidenced by:- The Administrator failed to ensure wound care policy was implemented for one of two sampled patients (Patient 2).- The Administrator failed to ensure the supervision for the LVN policy was implemented for one of two sampled patients (Patient 2).These failures had the potential risk to negatively impact the hospice’s operational performance.Findings: Review of the hospice’s Administrator Job Descriptions revised April 2020 showed the Administrator of the hospice will be responsible for the day-to-day operations of hospice. Review of the hospice’s P&P titled Responsibilities/Supervision of Clinical Services revised April 2020 showed the Clinical Director will be responsible for the direction of hospice and will take reasonable steps to ensure that care and services provided by the hospice personnel and contracted personnel are coordinated and integrated; policies and procedures that guide and support the provision of care and services are developed and implemented. The Clinical Director will ensure that the following supervision is maintained within hospice: LVN will be supervised by a registered nurse at least every 14 days or as directed by the State Practice Act, whichever is more frequent. Review of the hospice’s P&P titled Comprehensive Wound Care Assessment (undated) showed for ongoing reassessment of a wound, at each skilled nursing visit, the RN/LVN reassesses the wound. Weekly progress review at the IDG meeting. Documentation requirement for all wound notes must include objective data (measurements, staging, and condition of the wound), skilled nursing interventions performed, patient/PCG teaching provided, pain management strategies, and MD notification/orders obtained. Review of Patient 2’s clinical record was initiated on 9/18/25. The clinical record showed the SOC was on 6/19/25. The patient was certified for hospice services during the certification periods from 7/6/25 to 9/3/25 and 9/4/25 to 11/2/25. a. Review of the Comprehensive Nursing Assessment dated 6/19/25, showed the patient had Stage 2 pressure injury to sacrococcygeal area. Review of the SN Visit Notes Dated 7/17, 7/24, 7/31, 8/14, 8/26, 9/9, and 9/16/25, showed the wound assessments failed to include the measurements of the patient’s Stage 2 pressure injury to the sacrococcyx area. In addition, the SN Visit Notes dated 7/10, 8/7, 8/19, 9/4, and 9/11/25, failed to show documented evidence of wound assessments as per the hospice’s P&P. On 9/23/25 at 1233 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee. The DPCS/Administrator Designee stated for each SN visit, the nurse should assess the patient’s wound including the location, measurements, characteristics, signs of infection, and changes in appearance of the wound, and documented. The DPCS/Administrator Designee was informed and acknowledged the finding. b. Review of the Updated Assessment dated 7/17, 7/31, 8/14, 8/26, 9/9, and 9/16/25, showed in the section of Supervisory Note, RN 1 evaluated LVN 3. With the question if LVN 3 demonstrated competence with assigned task, the documentation showed, “Yes.” However, review of the LVN Visit Notes dated 7/10, 8/7, 8/19, 9/4, and 9/11/25, failed to show documented evidence wound assessments were completed as per the hospice’s P&P. On 9/23/25 at 1309 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee. The DPCS/Administrator Designee stated every two weeks, as part of the coordination with the LVN and RN, the RN would do supervisory visits to provide education to the LVN about wound management, abnormal vital signs, reporting of changes of condition and checking if the LVN is following the patient’s POC. The DPCS/ Administrator showed the LVN was in continuous communication with her regarding the patient’s progress; however, the DPCS/Administrator Designee verified there was no documented evidence the LVN completed wound assessments. The DPCS/Administrator Designee was informed and acknowledged the finding. Cross reference to L543, example 2.b.”

“Based on interview and record review, the hospice failed to ensure the patients’ clinical records were complete, accurate and submitted timely for two of two sampled patients (Patients 1 and 2). This failure had the potential risk of the patients receiving substandard care and disrupting the continuity of care due to incomplete, inaccurate, and untimely submitted documentation.Findings: Review of the hospice’s P&P titled Content of Clinical Records (undated) showed the hospice maintains complete, accurate, timely, and readily retrievable clinical records for all patients and families served. Entries must be completed, signed, and submitted within seven days of service. 1. Review of Patient 1’s clinical record was initiated on 9/18/25. The clinical record showed the SOC was on 6/9/25. The patient was certified for hospice services during the certification periods from 6/12/25 to 8/10/25 and 8/11/25 to 10/9/25. a. Review of the HA Visit Notes dated 7/28, 7/30, 8/13, 8/15, 8/18, 8/21, 8/25, 8/27, 9/5, 9/10, and 9/13/25, showed the HA conducted a home visit and a status of a red “X” symbol. However, the HA visit notes were incomplete. On 9/23/25 at 1101 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee. The DPCS/Administrator Designee stated the disciplines’ visit notes should be completed and submitted within seven days of the visit date. The DPCS/Administrator Designee was informed and acknowledged the finding. b. Review of the POC/IDG dated 6/18, 7/2, 7/16, 7/30, 8/13, and 8/27/25, showed a genitourinary problem of potential for altered bladder elimination related to BPH. Review of the Physician Order dated 6/9/25, showed an order to administer Tamsulosin hydrochloride (alpha blocker) 0.4 mg one caplet by mouth once daily for BPH. However, review of the Demographics showed the patient’s gender was female. On 9/23/25 at 11124 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee. The DPCS/Administrator Designee stated the documented diagnosis of BPH was an incorrect. The DPCS/Administrator Designee was informed and acknowledged the finding. 2. Review of Patient 2’s clinical record was initiated on 9/18/25. The clinical record showed the SOC was on 6/19/25. The patient was certified for hospice services during the certification periods from 7/6/25 to 9/3/25 and 9/4/25 to 11/2/25. a. Review of the POC/IDG dated 7/16, 7/30, 8/13, 8/27, and 9/10/25, showed a POC in the genitourinary section, a goal the patient will manifest improved urine output within the target limit set by the healthcare provided; and the patient will participate in dialysis treatments as prescribed. In addition, the intervention included to explain the importance of dialysis. Review of the CTI, for the certification periods from 7/6/25 to 9/3/25 and 9/4/25 to 11/2/25, did not include documented evidence the patient had a diagnosis of End Stage Renal Disease nor was receiving dialysis treatment. On 9/23/25 at 1136 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee. The DPCS/Administrator Designee stated the patient was not on dialysis treatment. The DPCS/Administrator Designee was informed and acknowledged the finding. b. Review of the HA Visit Note dated 7/28/25, showed in the narrative section, “wound care to the sacral area was performed per MD orders and the patient tolerated the procedure well.” *However, review of the HA assignment dated 6/19/25, showed a task for the HA to visualize the condition of the skin and report to the RN every visit but not to provide wound treatment. On 9/23/25 at 1242 hours, an interview and concurrent clinical record review was conducted with the DPCS/Administrator Designee. The DPCS/Administrator Designee stated the HA’s documentation was inaccurate. The DPCS/Administrator Designee stated the HA was only supposed to report to the RN if there were changes in the patient’s skin condition and not provide wound treatment. The DPCS/Administrator Designee was informed and acknowledged the finding.”

“Based on interview and record review, the hospice failed to ensure the comprehensive assessments identified the emotional, psychosocial, and spiritual needs for one of two sampled patients (Patient 2). This failure had the potential risk of not providing care and services to meet the care needs for Patient 2.Findings: Review of the hospice’s P&P titled Comprehensive Assessment revised April 2020 showed a physical assessment, including blood pressure, temperature, pulse, respiration, skin, and other relevant data related to pertinent physical findings and the patient’s terminal illness.Review of Patient 2’s clinical record was initiated on 9/2/25. The clinical record showed the SOC was on 6/23/25. The patient was certified for hospice services during the certification periods from 6/23/25 to 8/21/25 and 8/22/25 to 10/20/25.Review of the Comprehensive Nursing Assessment dated 6/23/25, showed RN 1 had performed the initial comprehensive assessment. The assessment included the Vitals and Measurements sections. However, the section for height was left blank.On 9/2/25 at 1514 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and stated the sections in the assessment should all be completed.”

“Based on interview and record review, the hospice failed to ensure the initial bereavement assessment was completed for two of two sampled patients (Patients 1 and 2). This failure had the potential risk of not providing appropriate, consistent, and quality care to these patients. Findings: Review of the hospice’s P&P titled Initial Assessment revised April 2020 showed admitting registered nurse will determine the other disciplines to complete the appropriate sections of the comprehensive assessment based on identified problems and needs during this initial assessment. Nursing and bereavement sections will always be identified.Review of the hospice’s P&P titled Bereavement Assessment revised April 2020 showed on admission, the social worker or hospice registered nurse will complete a bereavement risk assessment that will be given to the Bereavement Coordinator. The Bereavement Coordination will review the bereavement risk assessment to determine the potential needs of the survivors.1. Review of Patient 1’s clinical record was initiated on 8/29/25. The clinical record showed the SOC was on 6/23/25. The patient was certified for hospice services during the certification periods from 6/23/25 to 8/21/25 and 8/22/25 to 10/20/25.Further review of the clinical record showed no documented evidence the initial bereavement assessment was completed.On 9/2/25 at 1453 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the finding.2. Review of Patient 2’s clinical record was initiated on 9/2/25. The clinical record showed the SOC was on 6/23/25. The patient was certified for hospice services during the certification periods from 6/23/25 to 8/21/25 and 8/22/25 to 10/20/25.Further review of the clinical record showed no documented evidence the initial bereavement assessment was completed.On 9/2/25 at 1515 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the finding.”

“Based on record review and interview, the hospice failed to ensure care and services were provided in accordance with the POC for two of tow sampled patients (Patients 1 and 2). This failure had the potential risk of not providing appropriate, consistent, and quality care to these patients.Findings: Review of the hospice’s P&P titled The Plan of Care revised April 2020 showed a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted in the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The procedure includes the plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs.Review of the hospice’s P&P titled Missed Visit revised 4/2020 showed missed visit will be communicated to the Interdisciplinary Group at the IDG Meeting. Missed visit will be documented in the clinical record. If a visit is missed for any reason, the clinician should attempt to reschedule for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. If a visit is missed and not rescheduled the clinician will notify the IDG and the clinical supervisor of the missed visit. If an aide visit is missed the aide will contact the case manager or clinical supervisor and the manager/supervisor will take the appropriate measures stated above.1. Review of Patient 1’s clinical record was initiated on 8/29/25. The clinical record showed the SOC was on 6/23/25. The patient was certified for hospice services during the certification periods from 6/23/25 to 8/21/25 and 8/22/25 to 10/20/25.*The POC/IDG Review for certification periods from 6/23/25 to 8/21/25 and 8/22/25 to 10/20/25, showed HA visit two times per week for assistance with ADL and personal cares.However, review of the HA Visit Notes showed the following:- For week 1 (from 6/23 to 6/28/25), there was no documented evidence of two HA visits as ordered in the POC.- For week 2 (from 6/29 to 7/5/25), there was no documented evidence of two HA visits as ordered in the POC.- For week 3 (from 7/6 to 7/12/25), there was no documented evidence of two HA visits as ordered in the POC.- For week 6 (from 7/27 to 8/2/25), there was one HA visit instead of two visits as ordered in the POC.- For week 7 (from 8/3 to 8/9/25), there was no documented evidence of two HA visits as ordered in the POC.- For week 8 (from 8/10 to 8/16/25), there was no documented evidence of two HA visits as ordered in the POC.*The POC/IDG Review dated 6/23, 6/26, 7/16, 7/30, and 8/13/25, showed SN visits two times per week and two PRN visits for change in condition and symptom management.However, review of the SN notes showed the following:- For the week of 6/23 to 6/28/25, there was one SN visit instead of two visits as ordered in the POC.- For the week of 6/29 to 7/5/25, there was one SN visit instead of two visits as ordered in the POC.- For the week of 7/6 to 7/12/25, there was one SN visit instead of two visits as ordered in the POC.- For the week of 7/13 to 7/19/25, there was one SN visit instead of two visits as ordered in the POC.- For the week of 7/20 to 7/26/25, there was one SN visit instead of two visits as ordered in the POC.- For the week of 7/27 to 8/2/25, there was no documented evidence of a SN visit as ordered in the POC.- For the week of 8/3 to 8/9/25, there was no documented evidence of two SN visit as ordered in the POC.- For the week of 8/10 to 8/16/25, there was no documented evidence of a SN visit as ordered in the POC.- For the week of 8/17 to 8/23/25, there was no documented evidence of two SN visits as ordered in the POC.- For the week of 8/24 to 8/30/25, there was one SN visit instead of two visits as ordered in the POC.*The POC/IDG Review dated 6/23, 6/26, 7/16, 7/30, 8/13, and 8/27/25, showed RN visit once every 14 days for comprehensive assessment and supervisory visit.Review of the SN Visit Notes dated 7/16 and 8/27/25, showed the RN had a home visit. However, further review of the SN Visit Notes failed to show documented evidence of the RN visit completed every 14 days for comprehensive assessment and supervisory visit as ordered per the POC.*The physician’s order dated 6/28/25, showed MSW visit once per month and as needed for psychosocial support to the patient and family.However, review of the clinical record failed to show documented evidence of a MSW visit for the month of July as per the physician’s order.Further review of the clinical record failed to show documented evidence of the attempt to reschedule the visit for the week as per the hospice’s P&P.On 9/2/25 at 1322 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS stated if there was a missed visit, the nurse should attempt to reschedule another visit within the same week. The DPCS further stated the missed visit should be reported to the physician and IDG, and the reason should be documented. The DPCS was informed and acknowledged the findings.2. Review of Patient 2’s clinical record was initiated on 9/2/25. The clinical record showed the SOC was on 6/23/25. The patient was certified for hospice services during the certification periods from 6/23/25 to 8/21/25 and 8/22/25 to 10/20/25.*The POC/IDG Review for the certification periods from 6/23/25 to 8/21/25 and 8/22/25 to 10/20/25, showed RN visit once every 14 days for comprehensive assessment and supervisory visit.Review of the SN Visit Notes dated 7/9 and 7/20/25, showed the RN had a home visit. However, further review of the SN Visit Notes failed to show documented evidence of the RN visit completed every 14 days for comprehensive assessment and supervisory visit as ordered per the POC.*The POC/IDG Review dated 7/30/25, showed SN visit once per week and three PRN visits for changes in condition and symptom management.However, review of the SN Visit Notes showed the following:- For the week of 8/3 to 8/9/25, there was no documented evidence of an SN visit as ordered in the POC.- For the week of 8/17 to 8/23/25, there was no documented evidence of an SN visit as ordered in the POC.The POC/IDG Review dated 6/26, 7/15, 7/30, and 8/13/25, showed HA visit two times per week – declined.However, review of the HA Visit Notes showed the following:- For the week of 7/27 to 8/2/25, there was one HA visit.- For the week of 8/3 to 8/9/25, there was no documented evidence of two HA visits as ordered.- For the week of 8/10 to 8/16/25, there was no documented evidence of two HA visits as ordered.Further review of the clinical record failed to show documented evidence of the attempt to reschedule the visit for the week as per the hospice’s P&P.On 9/2/25 at 1453 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS clarified the HA visit should had been two visits per week and the word “decline” was an inaccurate documentation. The DPCS was informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the individualized care plans were developed for two of two sampled patients (Patients 1 and 2). This failure had the potential risk to cause an inconsistent delivery of care which can result in the decline or lack of improvement of the patients’ health conditions.Findings: Review of the hospice’s P&P titled The Plan of Care revised April 2020 showed a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted in the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The procedure includes the plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs.1. Review of Patient 1’s clinical record was initiated on 8/29/25. The clinical record showed the SOC was on 6/23/25. The patient was certified for hospice services during the certification periods from 6/23/25 to 8/21/25 and 8/22/25 to 10/20/25.Review of the Psychosocial Assessment dated 6/28/25, showed the MSW conducted a visit. The narrative notes showed the MSW planned to visit the patient once per the recertification period and as necessary. In addition, the POC/IDG Reviews dated 7/16 and 7/30/25, showed the MSW visit once per recertification period and as necessary; and The POC/IDG Reviews dated 8/13 and 8/27/25, showed in the section of psychosocial, the MSW visit once per month offering psychosocial support to the patient and family.However, review of the POC/IDG Reviews dated 7/16, 7/30, 8/13 and 8/27/25, failed to show documented evidence a psychosocial care plan was developed to reflect the MSW assessment.On 9/2/25 at 1318 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the finding.2. Review of Patient 2’s clinical record was initiated on 9/2/25. The clinical record showed the SOC was on 6/23/25. The patient was certified for hospice services during the certification periods from 6/23/25 to 8/21/25 and 8/22/25 to 10/20/25.Review of the Psychosocial Assessment dated 6/28/25, and MSW Visit Note dated 8/26/25, showed the MSW conducted a visit. The narrative notes showed the MSW visit once every recertification period and as needed to continue to assess the patient’s needs and provide the appropriate resources and assistance.However, review of the POC/IDG Reviewa dated 7/16, 7/30, 8/13 and 8/27/25, failed to show documented evidence a psychosocial care plan was developed to reflect the MSW assessment.On 9/2/25 at 1515 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the finding.”

“Based on interview and record review, the hospice failed to ensure the POCs included measurable outcomes for two of twp sampled patients (Patients 1 and 2). This failure had the potential risk of not evaluating the POC and providing appropriate care and services to these patients. Findings: Review of the hospice’s P&P titled The Plan of Care revised April 2020 showed a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen days. This plan will focus on identified problems, goals, and interventions. The plan of care will include all services necessary for the palliation and management of the terminal illness and related conditions. The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care. The written plan of care will contain, but not limited to, the following: under letter T, measurable outcomes anticipated from implementing and coordinating the plan of care.1. Review of Patient 1’s clinical record was initiated on 8/29/25. The clinical record showed the SOC was on 6/23/25. The patient was certified for hospice services during the certification periods from 6/23/25 to 8/21/25 and 8/22/25 to 10/20/25.The POC/IDG Reviews dated 6/26, 7/16, 7/30, 8/13, and 8/27/25, showed the patient’s identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example:- The goal for impaired skin integrity related to immobility and incontinence was for the patient to experience maximized comfort and preserved dignity during end-of-life care.- The goal for self-care deficit related to cognitive and physical decline was for the patient to maintain level of comfort, dignity, and function.On 9/2/25 at 1411 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the finding.2. Review of Patient 2’s clinical record was initiated on 9/2/25. The clinical record showed the SOC was on 6/23/25. The patient was certified for hospice services during the certification periods from 6/23/25 to 8/21/25 and 8/22/25 to 10/20/25.The POC/IDG Reviews dated 6/25, 7/15, 7/30, 8/13, and 8/27/25, showed the patient’s identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for the patient’s identified problems. For example:- The goal for decreased cardiac output related to disease process as evidenced by unstable blood pressure was for the patient’s blood pressure to be normal range of the disease process and for the patient to have a stable cardiac rate in the next two weeks of treatment.- The goal for risk for adverse effects related to use of cholesterol-lowering medication was for the patient’s comfort and dignity will be maintained through minimized medication burden.- The goal for altered sleep pattern related to progression of disease process as evidenced by difficulty falling or staying asleep, fatigue, and verbal reports of poor sleep quality was for the patient to experience reduced anxiety and discomfort at bedtime.On 9/2/25 at 1520 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the finding.”

“Based on interview and record review, the hospice failed to ensure the IDG had reviewed/revised the patients’ POCs no less frequently than every 15 calendar days for one of two sampled patients (Patient 2). This failure had the potential risk for not providing appropriate, consistent, and quality care to Patient 2.Findings: Review of the hospice’s P&P titled the Plan of Care revised April 2020 showed the plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the IDG and will be reviewed on a regular basis but no less than every fifteen (15) days.Review of Patient 2’s clinical record was initiated on 9/2/25. The clinical record showed the SOC was on 6/23/25. The patient was certified for hospice services during the certification periods from 6/23/25 to 8/21/25 and 8/22/25 to 10/20/25.The physician’s order dated 6/28/25, showed MSW visit once every recertification period and as needed for psychosocial support.The initial Spiritual Assessment dated 6/27/25, showed the patient and PCG declined the offer of a spiritual care services.Review of the POC/IDG Reviews dated 6/25, 7/15, 7/30, 8/13, and 8/27/25, the section of the Frequency of Visit, showed HA visit two times per week-decline and SN visit once per week and three PRN visits. *However, the section of the Frequency of Visit was not revised to reflect the MSW visit as per the physician’s order and the spiritual care services decline as per the Spiritual Assessment.On 9/2/25 at 1525 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS stated the HA frequency visit was supposed to be two times per week and should not be declined. The DPCS further stated the POC should had been updated to reflect the services the patient received per the POC. The DPCS was informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the IDG maintained the responsibility for directing, coordinating, and supervising the care and services provided for two of two sampled patients (Patients 1 and 2). This failure had the potential risk of not addressing the care needs for these patients. Findings: Review of the hospice’s P&P titled IDG Coordination of Care revised April 2020 showed the hospice will utilize a case management system to guide an IDG to provide comprehensive, coordinated hospice care to patients and family/caregivers. It will be the responsibility of the Clinical Supervisor/Nursing Supervisor to assign a Case Manager who is a RN. The Case Manager will be responsible for coordination of services with the IDG from referral to discharge. The type and scope of services provided by the IDG will be based upon the comprehensive and ongoing assessment regarding the needs of the patient and the family/caregiver and the comprehensive plan of care that defines patient and family/caregiver problems, goals, and interventions. The IDG will maintain responsibility for the provision and coordination of care, regardless of the setting where care is provided to its patients.Review of the hospice’s P&P titled Missed Visit revised 4/2020 showed missed visit will be communicated to the Interdisciplinary Group at the IDG Meeting. Missed visit will be documented in the clinical record. If a visit is missed for any reason, the clinician should attempt to reschedule for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. If a visit is missed and not rescheduled the clinician will notify the IDG and the clinical supervisor of the missed visit. If an aide visit is missed the aide will contact the case manager or clinical supervisor and the manager/supervisor will take the appropriate measures stated above.Review of Patients 1 and 2’s clinical records showed the disciplines did not conduct the visits as cited in the POC. Cross reference to L543, examples #1 and #2.However, there was no documented evidence the IDG notification regarding the missed visits as per the hospice’s P&P. There was no documented evidence of the IDG discussion regarding the missed visits during the IDG meetings for these patients. The IDG failed to maintain the responsibility for supervising the care and services provided to the patients.On 9/2/25 at 1322 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS stated there should be a documented communication for the missed visit to a patient. The DPCS stated the missed visit should be discussed and coordinated with the physician and IDG. The DPCS stated during the IDG meetings every two weeks, the IDG discussed the hospice’s admission, discharges, patient’s changes of condition, psychosocial needs, spiritual needs, new physician’s orders, and missed visits. The DPCS was informed and verified there was no documented evidence to show the disciplines’ missed visits were communicated and coordinated to the physician or the IDG.”

“Based on interview and record review, the hospice failed to ensure the physician reviewed the patient’s clinical information to recertify the patient for hospice services for two of two sampled patients (Patients 1 and 2). This failure had the potential risk of not identifying the care needs for these patients.Findings: Review of the hospice’s P&P titled Certification of Terminal Illness revised April 2020 showed the patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician and the hospice Medical Director. Hospice services will be provided in two (2) 90-day periods and an unlimited number of 60-day periods if the patient is recertified at the beginning of each benefit period. A subsequent recertification, at the beginning of each new benefit period, may be signed by the attending physician or the hospice Medical Director. At recertification, the hospice Medical Director must compose and sign the narrative based on a review of the patient’s medical record or, if applicable, examination of the patient. A verbal or written certification statement must be obtained from the Medical Director or the attending physician no more than fifteen (15) calendar days prior or two (2) calendar days after the first day of each period. The signed and dated certification must be present prior to billing for each recertification period.1. Review of Patient 1’s clinical record was initiated on 8/29/25. The clinical record showed the SOC was on 6/23/25. The patient was certified for hospice services during the certification periods from 6/23/25 to 8/21/25 and “8/22/25 to 10/20/25.”Review of the Physician’s Certification for Hospice Benefit showed Certification #27: Re-Certification Statement for the Next 60-day period for the effective date of certification from 8/22/25 to 10/20/25. However, the sections for RN prognosis summary, physician narrative, certifying physician narrative, and physician signature were left blank.Further review of the clinical record showed the patient continued to receive hospice services on 8/22, 8/25, 8/27, and 8/28/25.However, there was no documented evidence the certification of terminal illness was completed prior to the patient receiving hospice services on 8/22/25. On 9/2/25 at 1312 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS stated the CTI was pending for the physician to complete. The DPCS was informed and acknowledged the finding.2. Review of Patient 2’s clinical record was initiated on 9/2/25. The clinical record showed the SOC was on 6/23/25. The patient was certified for hospice services during the certification periods from 6/23/25 to 8/21/25 and “8/22/25 to 10/20/25.”Review of the Physician’s Certification for Hospice Benefit showed Certification #8: Re-Certification Statement for the Next 60-day period for the effective date of certification from 8/22/25 to 10/20/25. However, the section for the RN prognosis summary, physician narrative, certifying physician narrative, and physician signature were left blank.Further review of the clinical record showed the patient continued to receive hospice services on 8/23, 8/26, and 8/28/25.However, there was no documented evidence the certification of terminal illness was completed prior to the patient receiving hospice services on 8/23/25. On 9/2/25 at 1531 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the finding.”

“Based on interview and record review, the hospice failed to ensure the patients’ clinical records were complete, accurate and submitted timely for two of two sampled patients (Patients 1 and 2). This failure had the potential risk of the patients receiving substandard care and disrupting the continuity of care due to incomplete, inaccurate, and untimely submitted documentation.Findings: Review of the hospice’s P&P titled Content of Clinical Records (undated) showed the hospice maintains complete, accurate, timely, and readily retrievable clinical records for all patients and families served. Entries must be completed, signed, and submitted within 7 days of service. The POC is established by IDG, updated at least every 15 days, signed by the physician.1. Review of Patient’s 1’s clinical record was initiated on 8/29/25. The clinical record showed the SOC was on 6/23/25. The patient was certified for hospice services during the certification periods from 6/23/25 to 8/21/25 and 8/22/25 to 10/20/25.a. Review of the Visit Notes dated 7/3, 7/8, and 7/24/25, showed a LVN conducted a home visit, and a status of a red “X” symbol. However, the visit notes were incomplete.On 8/29/25 at 1425 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator stated the red “X” symbol meant the visit notes were not submitted and incomplete. The Administrator was informed and acknowledged the finding.b. Review of the POC/IDG Reviews dated 6/26/25 and 7/16/25, showed the IDG meetings were conducted on 6/26 and 7/16/25, more than 15 days.On 9/2/25 at 1335 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS stated there was an IDG meeting held on 7/2/25. The DPCS provided documentation of the sign-in sheet for the IDG meeting dated 7/2/25, and a summary report description for each of the hospice’s patients. The DPCS stated when the IDG meeting was held, the patient’s change of condition and care needs were discussed. However, the DPCS verified there was no documented evidence of a completed comprehensive assessment for Patient 1.2. Review of Patient 2’s clinical record was initiated on 9/2/25. The clinical record showed the SOC was on 6/23/25. The patient was certified for hospice services during the certification periods from 6/23/25 to 8/21/25 and 8/22/25 to 10/20/25.a. Review of the POC/IDG Reviews dated 6/26, 7/15, 7/30, 8/13, and 8/27/25, showed the section of the frequency of visits HA visit two times per week showing “decline.”On 9/2/25 at 1525 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS stated the word decline was a wrong documentation. The DPCS stated the patient was receiving HA visits two times per week. The DPCS was informed and acknowledged the finding.b. Review of the POC/IDG Review dated 6/25 and 7/15/25, showed an IDG meeting was conducted on 6/25 and 7/15/25, more than 15 days.On 9/2/25 at 1510 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS stated there was an IDG meeting held on 7/2/25. The DPCS provided documentation of the sign-in sheet for the IDG meeting dated 7/2/25 and a summary report description for each of the hospice’s patients. The DPCS stated when the IDG meeting was held, the patient’s change of condition and care needs were discussed. However, the DPCS verified there was no documented evidence of a completed comprehensive assessment for Patient 2.”

“Based on interview and record review, the hospice failed to ensure the comprehensive assessment was completed no later than five calendar days after the election of hospice care for one of one sampled patient (Patient 1). This failure created the potential risk for not addressing the care needs for this patient. Findings: Review of Patient 1’s closed clinical record was initiated on 7/2/25. The clinical record showed the SOC was on 5/30/25. The patient was certified for hospice services during the certification period from 5/30/25 to 8/27/25. The patient was discharged and revoked hospice services on 6/10/25.The election of hospice benefit form dated 5/30/25, showed Patient 1 signed for hospice services.The initial Spiritual Care Assessment dated 6/7/25, showed no documented evidence the SCC assessed the sections for “ALTERATIONS/PROBLEMS REPORTED OR SUSPECTED” and “REPORTED OR SUSPECTED ASSISTANCE NEEDS.” Documentation showed the patient’s bereavement risk was not completed.* However, there was no documented evidence the comprehensive spiritual assessment was completed no later than five calendar days after the election of hospice care.On 7/3/25 at 1407 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/Owner. The Administrator/Owner stated the spiritual care assessment was completed more than five days of the election of hospice care because of the patient or family’s schedule request. However, there was no documented evidence to show the SCC visit was requested for 6/7/25. The Administrator/Owner was informed and acknowledged the above finding.”

“Based on interview and record review, the hospice failed to ensure the medication profile was reviewed and updated to reflect the current medications and include the specific instructions for its use for one of one sampled patient (Patient 1). This failure had the potential for the patient to not receive the appropriate care and necessary services and negatively affect the patients’ well-being.Findings: Review of the hospice’s P&P titled Medication Profile revised 3/1/12, showed the nurse responsible for the tuck in visit and/or initial comprehensive assessment will complete the medication profile ordered by the attending physician during the admission process. The medications listed on the POC are those related to the palliation and management of the terminal illness as covered medication. The RN case manager and/or QA personnel will review and update, correct as necessary.Review of Patient 1’s closed clinical record was initiated on 7/2/25. The clinical record showed the SOC was on 5/30/25. The patient was certified for hospice services during the certification period from 5/30/25 to 8/27/25. The patient was discharged and revoked hospice services on 6/10/25.The physician’s order dated 6/8/25, showed the following orders:-morphine concentrate (opioid analgesic) 5 mg (20 mg/ml) SL for moderate breakthrough pain 4-6 (on a 0-10 pain scale, with 0=no pain and 10=worst pain) Q four hours PRN-morphine concentrate 10 mg (20 mg/ml) SL for severe breakthrough pain level of 7-10 Q four hours PRN* However, the morphine orders did not have specific instructions of how much the amount of 5 mg or 10 mg were equivalent to in ml(s) to administer to the patient.On 7/3/25 at 0810 hours, an interview and concurrent closed clinical record review was conducted with RN 1. RN 1 stated the morphine bottle that was delivered to Patient 1 had a medication label showing to give 0.25 ml for 5 mg and 0.5 ml for 10 mg dose. RN 1 stated there should be specific equivalence of the dosage of mg to ml in the physician’s orders. RN 1 was informed and acknowledged the above finding.On 7/3/25 at 1407 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/Owner. The Administrator/Owner was informed and acknowledged the above finding.”

“Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POC for one of one sampled patient (Patient 1). This failure had the potential risk of not providing appropriate, consistent, and quality care to Patient 1. Findings: Review of Patient 1’s closed clinical record was initiated on 7/2/25. The clinical record showed the SOC was on 5/30/25. The patient was certified for hospice services during the certification period from 5/30/25 to 8/27/25. The patient was discharged and revoked hospice services on 6/10/25. The physician’s order dated 6/8/25, showed the following orders:-morphine concentrate (opioid analgesic) 5 mg (20 mg/ml) SL for moderate breakthrough pain 4-6 Q four hours prn-morphine concentrate 10 mg (20 mg/ml) SL for severe breakthrough pain 7-10 Q four hours prn The Hospice Nursing Clinical Note dated 6/9/25, showed the following documentation:- “1545, Morphine 5 mg administered PO/SL administered PO/SL for pain management.”- “1800, pt noted with episode of grimace, moaning rate pain 5/10, SN administered Morphine prn 5mg PO/SL for pain management with good effective.”- “2000, Morphine 5 mg administered PO/SL for pain management.”- “2200, Pt noted with episode of grimace, moaning rate pain 4/10. Morphine 5 mg administered PO/SL for pain management.” *However, there was no documented evidence of the physician’s orders or plan of care for morphine 5 mg to be administered every two hours to the patient. On 7/3/25 at 1319 hours, a telephone interview was conducted with RN 1. RN 1 was informed and stated when a patient was in continuous care, an order for morphine in small doses can be given every two hours to relieve anxiety and shortness of breath to help the patient’s condition when the patient was struggling. RN 1 further stated the LVN should have clarified the morphine order to be given every two hours routinely or as needed. RN 1 acknowledged the above finding. On 7/3/25 at 1415 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/Owner. The Administrator/Owner was informed and acknowledged the above finding.”

“Based on interview and record review, the hospice failed to ensure the individualized care plans were developed for one of one sampled patient (Patient 1). This failure created the potential risk to cause inconsistent delivery of care which can result in the decline or lack of improvement of the patient’s health conditions.Findings: Review of the hospice’s P&P titled Hospice Plan of Care and Treatment dated 5/10/02, showed an individualized plan of care/treatment will be established for every patient accepted for the care. This written plan shall be developed in consultation with the Interdisciplinary Team. The plan will be reviewed and updated at intervals specified. The care is to be used as a treatment guide for all disciplines and will be part of the patient’s permanent record. The content of the plan of care include:- diagnoses- assessment of patient/family needs including medical, nursing, functional, psychosocial, and spiritual status- appraisal of and need for symptom control- mental status- assessment of family needs as related to care of patient- types of services and equipment required- frequency of visits, treatments, and medications- instructions to patient and family- nutritional problems/requirements- statement of treatment goals, rehab potential- prognosis, discharge, referral plan- activities/ functional limitations/ safety measures- identifications of discipline responsible for each intervention/ service-methods of evaluation/ follow up Review of Patient 1’s closed clinical record was initiated on 7/2/25. The clinical record showed the SOC was on 5/30/25. The patient was certified for hospice services during the certification period from 5/30/25 to 8/27/25. The patient was discharged and revoked hospice services on 6/10/25. a. The admission physician’s orders dated 5/30/25, showed the following orders:-Okay to access left chest port for IVF, IV Zofran (a drug to prevent nausea and vomiting)-NS 1000 ml Q 24 hours via port over 2-4 hours at 250-500 ml per hour-Zofran 8 mg IV Q eight hours for nausea and vomiting.* However, there was no documented evidence the IDG had developed an individualized POC to address Patient 1’s left chest port site, access care, and IV medication administration. b. The Medication Profile showed an order dated 5/31/25, for morphine sulfate (opioid analgesic) 2 mg (20 mg/ml) Q one hour PRN for break through pain.Review of the Hospice Nursing Clinical Note dated 6/6/25, showed documentation of “Pt stated last night had severe pain, her daughter gave her Morphine liquid 20 mg=1ml at 11 pm with effective.”The physician’s order dated 6/8/25, showed the following orders:-morphine concentrate (opioid analgesic) 5 mg (20 mg/ml) SL for moderate breakthrough pain 4-6 Q four hours prn-morphine concentrate 10 mg (20 mg/ml) SL for severe breakthrough pain 7-10 Q four hours prnThe Hospice Nursing Note dated 6/8/25, showed, “Family Reports although Patient with No S/S pain, patient was requesting 20 MG MORPHINE SL instead of 5-10 Mg as Ordered.” Documentation showed the SN assessed the patient would then become sedated with decreased verbal response and change in breathing. Documentation showed the patient was receiving morphine 20 mg in AM and sleeping with decreased level of consciousness after the dose.* However, there was no documented evidence the IDG had developed an individualized POC to address Family Member 1’s noncompliance of administering morphine 20 mg to the patient. c. Review of the hospice’s P&P titled Change in Condition-Continuous Care revised 3/1/02, showed during periods of acute medical crisis for patients residing at home or nursing facility, boarding care, a change of condition where frequent SN visits do not meet the patient’s medical need, “continuous care” may be necessary. The patient must require primarily skilled nursing care for palliation or management of acute medical symptoms to be eligible to receive continuous care. The hospice case manager will, under section number 5, update the plan of care.The physician’s order dated 6/9/25, showed to start continuous care on 6/9/25, for pain and respiratory management.Review of the Hospice Nursing Clinical Note dated 6/9/25, showed care plan problems for pain, respiratory, GI/GU/nutritional/endocrine, and integumentary.* However, there was no documented evidence the IDG had developed an individualized POC to reflect Patient 1’s start of continuous care. On 7/3/25 at 0810 hours, an interview and concurrent closed clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the above findings. On 7/3/25 at 1415 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/Owner. The Administrator/Owner was informed and acknowledged the above findings.”

“Based on interview and record review, the hospice failed to ensure the clinical record was authenticated and dated timely in accordance with the hospice’s P&P for one of one sampled patient (Patient 1). This failure had the potential risk of substandard care provided to Patient 1 as the clinical information was not completed timely.Findings: Review of the hospice’s P&P titled Authentication of Clinical Record revised 3/1/23, showed to ensure the integrity of documentation correction and submission, the hospice establishes and implements a monitoring system to track medical record charting, correction process, timely submission per state and federal regulations. At the time, before, after or during the visit, the discipline opens/creates a visit note or start of care as the assignment. This visit note includes the date, the time arrival and time leave, and mileage. After the visit, the discipline completes the visit documentation and select “Send To the Office” button. If it is a start of care, the initial documentation is to be done within 2 to 3 days and complete within 5 days. If it is a routine visit note, the documentation is to be done within 30 days or sooner pending on payer’s rule. Review of Patient 1’s closed clinical record was initiated on 7/2/25. The clinical record showed the SOC was on 5/30/25. The patient was certified for hospice services during the certification period from 5/30/25 to 8/27/25. The patient had revoked hospice services and was discharged on 6/10/25. Review of the initial Medical Social Services Assessment showed on 6/3/25, the MSW conducted a visit. *However, the MSW’s documentation was electronically signed on 6/7/25. In addition, the MSW did not include a documentation of her mileage information. The MSW did not complete the signature within 5 days nor include the mileage information per the hospice’s P&P. On 7/3/25 at 1415 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/Owner. The Administrator/Owner was informed and acknowledged the above finding. The Administrator/Owner stated the comprehensive assessment should be signed within 5 days of the election of hospice care.”