Roze Room Hospice

“Based on observation, interview, and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure the Condition of Participation (CoP-a set of minimum professional standards all hospice agencies must meet to participate in Medicare [federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) for Initial & Comprehensive Assessment of Patient was met as follows: a. The HA failed to conduct and document an accurate comprehensive wound assessment (initial and ongoing) that reflected the patient’s current health status and identify patients’ need for hospice care and services related to wound management for three of 23 sampled patients (Patients 5, Patient 13 and Patient 17) by failing to: Obtain wound care treatment orders and inform the physician of Patient 17’s Stage 2 pressure ulcer on the coccyx initially identified on 1/11/2025. On 2/25/2025, RN 1 identified another pressure ulcer on Patient 17’s left buttock Stage 3 (full thickness skin loss). There was no physician’s order for treatment. (Hospice policy and procedure entitled” Wound Care”, revised dated 1/9/2023- When a wound is initially identified, the interdisciplinary team will be consulted and physician’s order for treatments obtained.)Assess accurately the worsening pressure ulcers for Patient 17 and Patient 5 and inform the physician for further treatment and intervention. Document in the comprehensive assessments of Patients 17 and Patient 5 pressure ulcers status that included location, size, stage, depth, presence or absence of drainage, description of any drainage, description of surrounding tissue and any discomfort to the patient. (Hospice policy and procedure entitled” Wound Care”, revised dated 1/9/2023).Develop the plan of care (POC) for wound care management for Patient 17 and Patient 5’s worsening pressure ulcers. The noncompliance resulted in pressure ulcers were not addressed with the interdisciplinary team and had not obtained a physician’s order for treatments and intervention leading to the worsening status of Patient 5 and Patient 17 pressure ulcers. (Refer to L524). b. The HA failed to maintain an accurate, current medication profiles for two of 23 sampled patients (Patient 13 and Patient 16). This failure has the potential in placing the patient at risk for medication errors and adverse drug reactions. (Refer to L530). The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily (written law) mandated compliance with Federal regulation for Initial and Comprehensive Assessment of the Patient to ensure the highest quality of care are being provided to patients certified to receive the Medicare hospice benefits.”

“Based on observation, interview, and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure the Condition of Participation (CoP-a set of minimum professional standards all hospice agencies must meet to participate in Medicare [federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) for IDG, CARE PLANNING, COORDINATION OF SERVICES of Patient was met as follows: a. The HA failed to develop an individualized written Plan of Care (POC, a document that maps out needs and services supplied for a Medicare patient facing a terminal illness, as well as the patient’s family/caregiver) that identified significant changes of the patient’s wound status, and update the identified changes in the comprehensive assessment for one of 23 sampled patients (Patient 13). Patient 13 had an existing Stage 2 left buttocks pressure ulcer; there was no care plan developed for wound care management. This deficient practice placed the patient’s wound at risk for slow wound healing and complications. (Refer to L545). b. The hospice agency (HA) failed to ensure prescribed medications including CVS Vitamin B12 (a dietary supplement), Vitamin D3 (a dietary supplement), Megestrol Acetate (used to treat advanced cancer), Sucralfate suspension (to treat stomach ulcers), and Ativan (to treat anxiety) were available for consumption for one of 23 sampled patients (Patient 16). This failure had the potential to compromise the health and safety of Patient 16. (Refer to L549). c. Hospice agency failed to coordinate services in accordance with the POC for 2 of 23 sample patients (Patient 5 and Patient 17) by failing to: Coordinate and provide hospice aide services as ordered on the POC. Ensure nursing services assessed the patient’s pressure ulcers that included pressure ulcer measurements for Patient 5 and Patient 17. This failure has the potential risk to impede the healing process causing deterioration and or worsening of the pressure ulcers leading to infection, pain, and discomfort of the hospice patients. Refer to L554. The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily (written law) mandated compliance with Federal regulation for IDG, CARE PLANNING, COORDINATION OF SERVICES of the Patient to ensure the highest quality of care are being provided to patients certified to receive the Medicare hospice benefits.”

“Based on observation, interview, and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure the Condition of Participation (CoP-a set of minimum professional standards all hospice agencies must meet to participate in Medicare [federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) for Clinical Records of Patient was met as follows: a. The HA failed to conduct and document an accurate comprehensive wound assessment (initial and ongoing) that reflected the patient’s current health status and identify patients’ need for hospice care and services related to wound management for three of 23 sampled patients (Patients 5, Patient 13 and Patient 17) by failing to: Document in the comprehensive assessments of Patients 17 and Patient 5 pressure ulcers status that included location, size, stage, depth, presence or absence of drainage, description of any drainage, description of surrounding tissue and any discomfort to the patient. (Hospice policy and procedure entitled” Wound Care”, revised dated 1/9/2023).Develop the plan of care (POC) for wound care management for Patient 17 and Patient 5’s worsening pressure ulcers. The noncompliance resulted in pressure ulcers were not addressed with the interdisciplinary team and had not obtained a physician’s order for treatments and intervention leading to the worsening status of Patient 5 and Patient 17 pressure ulcers. (Refer to L524). a. the HA failed to maintain accurate ,complete and timely clinical records for three of 26 sampled patients, (Patient 5,Patient 13, and Patient 17), resulting in incomplete assessment data, inconsistent wound documentation, and the inability to accurately track wound progression or healing. The failure to maintain accurate and consistent wound documentation for these patients compromised the hospice’s ability to evaluate the effectiveness of wound treatments, communicate accurate information during IDG meetings, and ensure continuity of care. (Refer to L672). The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily (written law) mandated compliance with Federal regulation for CLINICAL RECORDS of the Patient to ensure the highest quality of care are being provided to patients certified to receive the Medicare hospice benefits.”

“Based observation, interview, and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to conduct and document an accurate comprehensive wound assessment (initial and ongoing) that reflected the patient’s current health status and need for hospice care and services related to wound care management for three of 23 sampled patients (Patients 5, Patient 13 and Patient 17) by failing to: Obtain wound care treatment orders and inform the physician of Patient 17’s Stage 2 pressure ulcer on the coccyx initially identified on 1/11/2025. On 2/25/2025, RN 1 identified another pressure ulcer on Patient 17’s left buttock Stage 3 (full thickness skin loss). There was no physician’s order for treatment. (Hospice policy and procedure entitled” Wound Care”, revised dated 1/9/2023- When a wound is initially identified, the interdisciplinary team will be consulted and physician’s order for treatments obtained.) Assess accurately the worsening pressure ulcers for Patient 17 and Patient 5 and inform the physician for further treatment and intervention. Document in the comprehensive assessments of Patients 17 and Patient 5 pressure ulcers status that included location, size, stage, depth, presence or absence of drainage, description of any drainage, description of surrounding tissue and any discomfort to the patient. (Hospice policy and procedure entitled” Wound Care”, revised dated 1/9/2023). Develop the plan of care (POC) for wound care management for Patient 17 and Patient 5’s worsening pressure ulcers. The noncompliance resulted in pressure ulcers were not addressed with the interdisciplinary team and had not obtained a physician’s order for treatments and intervention leading to the worsening status of Patient 5 and Patient 17 pressure ulcers. On 8/5/2025 at 3:05 p.m., the California Department of Public Health (CDPH) called an Immediate Jeopardy (IJ, a situation in which the provider’s non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the Director Of Patient Care Services (DPCS), Administrator (ADM) and Chief Executive Officer (CEO) related to the hospice agency’s (HA, agency who provides specialized care and support for people with a serious illness who are nearing the end of life) due to: The Hospice Agency (HA, an agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to conduct and document an accurate comprehensive wound assessment (initial and ongoing) that reflected the patient’s current health status and identify patients’ need for hospice care and services related to wound management for two of 23 sampled patients (Patients 5 and Patient 17) by failing to: Obtain wound care treatment orders and inform the physician of Patient 17’s stage 2 pressure ulcer on the coccyx initially identified on 1/11/2025. (Hospice policy and procedure entitled” Wound Care”, revised dated 1/9/2023- When a wound is initially identified, the interdisciplinary team will be consulted and physician’s order for treatments obtained). Assess accurately the worsening pressure ulcers for Patient 17 and Patient 5 and inform the physician for further treatment and intervention. Document the comprehensive assessments of Patients 17 and Patient 5 pressure ulcers status that included location, size, stage, depth, presence or absence of drainage, description of any drainage, description of surrounding tissue and any discomfort to the patient. On 2/25/2025, RN 1 identified another pressure ulcer on Patient 17’s left buttock Stage 3 (full thickness skin loss). There was no physician’s order for treatment. (Hospice policy and procedure entitled” Wound Care”, revised dated 1/9/2023). Develop the plan of care (POC) for wound care management for Patient 17 and Patient 5’s worsening pressure ulcers. On 8/5/2025 at 4:10 p.m., the survey team completed the survey tasks and conducted an exit conference while onsite in the presence of the Director Of Patient Care Services (DPCS), Administrator (ADM) and Chief Executive Officer (CEO) On 8/5/2025, at 4:15 p.m., the HA was unable to submit an IJ removal Plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). The survey team exited from the HA with IJ not removed. a. During a review of Patient 13’s “Personal Information”, indicated a start of care (SOC) date of 7/19/2025, with a primary diagnosis of cerebrovascular accident (CVA- a stroke that occurs when blood flow to the brain is interrupted, causing brain damage). During a review of Patient 13’s POC/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 7/19/2025, indicated the frequency of visits for skilled nurse (SN) one to two visits per week plus two PRN (pro re nata, “as needed”) visits for assessments, comfort measures, and symptoms management) and Hospice Aide (HA) to visit once a week for personal care, home making, and to promote comfort. A review of Patient 13’s Active Orders dated 7/22/2025, indicated to provide wound care treatment to Stage 2 left buttocks pressure ulcer as follows: to clean with wound spray, pat dry, apply Zinc Oxide and cover with Optifoam dressing. During a home visit on 7/31/2025, at 12:30 p.m., with RN 1, Patient 13 was observed lying in bed alert and oriented x 4 (person, place, time, and event). RN 1 was observed providing wound treatment at Patient 13’s Stage 2 left buttocks pressure ulcer with no drainage present. On 7/31/2025, at 1 p.m., during an interview with RN 1, stated she does wound assessments on every visits and she measures the Stage 2 left buttocks pressure ulcer once a week according the POC. A review of Patient 13’s Clinical Notes from dated 7/24, 7/25,7/28, 7/29/7/30/2025, indicated there was no wound assessment and wound treatment provided to Stage 2 left buttocks pressure ulcer. During a concurrent interview and record review on 8/1/2025 at 10:30 AM, of Patient 13’s physician’s order was reviewed. The ADM stated that the hospice nurses should perform wound measurements during home visits to track the progression of the wound, identify potential complications, and ensure appropriate treatment. b. During a review of Patient 17’s “Personal Information”, indicated a start of care (SOC) date of 1/10/2025, with a primary diagnosis of congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should). During a review of Patient 17’s POC/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 7/30/2025, indicated the frequency of visits for skilled nurse (SN) one to two visits per week plus two PRN (pro re nata, “as needed”) visits for assessments, comfort measures, and symptoms management) and Hospice Aide (HA) to visit once a week for personal care, home making, and to promote comfort. During a record review of Patient 17’s Initial Clinical Note Visit dated 1/11/2025, identified Patient 17 had a Stage 2 (partial thickness skin loss appearing as a shallow, open ulcer with red or pink wound bed) pressure ulcer on the coccyx (tailbone), the visiting nurse however, failed to perform a comprehensive wound assessment that included location, size, stage, depth, presence or absence of drainage, description of any drainage, description of surrounding tissue and any discomfort to the patient. There was no documented evidence the visiting nurse provided wound treatment during the visit. A review of Patient 17’s Clinical Notes from dates 1/13/2025 through 1/30/2025, indicated there was no wound assessment and wound treatment provided to Stage 2 pressure ulcer. From 1/13/2025 through 2/27/2025, the visiting nurses conducted home visits to Patient 17’s residence but failed to document an accurate wound assessment. A review of Patient 17’s Supplemental order dated 1/30/2025, indicated to provide wound care treatment to Stage 2 coccyx pressure ulcer as follows: to clean with normal saline, pat dry, apply Zinc ointment with Optifoam dressing. A review of Patient 17’s Routine visit note dated 2/25/2025 indicated RN 1 identified Patient 17’s left buttock Stage 3 (full thickness skin loss) measuring 5 cm in length by 5 cm in width. A review of Patient 17’s Supplemental Order notes indicated that there was no wound treatment order found for the patient’s newly identified Stage 3 left buttocks pressure ulcer. A review of Patient 17’s physician’s order was reviewed. The Administrator (ADM) confirmed the hospice staff did not inform the physician to obtain a wound treatment order until 1/30/2025. During a review of Patient 17 plan of care indicated the hospice staff did not develop a plan of care for wound management. The clinical note dated 3/4/2025, indicated the wound at sacral/coccyx area had progressed from Stage 2 to Stage 4 (full thickness skin and tissue loss exposing bone, muscle or tendon). There was no documented evidence the comprehensive assessment of the wound was performed by the hospice staff. A review of Patient 17’s Supplemental order dated 1/30/2025, indicated to provide wound care at Stage 4 coccyx pressure ulcer as follows: to clean with normal saline, pat dry, apply Xeroform and Bordered dressing every day or as needed for soiling. During a concurrent interview and record review on 8/1/2025 at 10:30 AM, of Patient 17’s physician’s order was reviewed. The Administrator (ADM) confirmed the hospice staff did not obtain a wound treatment order until 1/30/2025. The ADM stated that the progression of the pressure ulcer can be avoided if wound was assessed correctly and coordinated with the physician for proper treatment. The ADM stated that the hospice nurses should perform wound measurements during home visits to track the progression of the wound, identify potential complications, and ensure appropriate treatment. During a home visit on 8/1/2025, at 1:50 p.m., with RN 1, Patient 17 was observed lying in bed alert and oriented x 4 (person, place, time, and event). RN 1 was observed providing wound treatment at Patient 17’s Stage 4 coccyx pressure ulcer with measurements of 3.8 centimeters (cm) in length by 1.9 cm in width by 0.3 cm in depth with no drainage nor odor. On 8/1/2025, at 2:30 p.m., during an interview with RN 1, stated he was assigned to Patient 17 from March to June 2025, and during those visits, RN 1 measured Patient 17 coccyx pressure ulcer once. RN 1 stated he should have measured Patient 17’s wound once every week every visit according the POC. During a concurrent interview and record review on 8/5/2025 at 12:40 p.m., with the director of patient care services (DPCS), when she was asked if the physician was not notified about the patient with a newly identified Stage 3 pressure ulcer, the DPCS stated she could not find any documentation to show the physician was notified. c. . During a review of Patient 5’s “Personal Information”, indicated a start of care (SOC) date of 1/2/2025, with a primary diagnosis of breast cancer. During a review of Patient 5’s POC/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 1/22/2025, indicated the frequency of visits for skilled nurse (SN) one to two visits per week plus three PRN (pro re nata, which means “as needed”) visits for assessments, comfort measures, and symptoms management) and Hospice Aide (HA) to twice a week for personal care, home making, and to promote comfort. During a record review of Patient 5’s clinical records indicated that in the initial assessment dated 1/4/2025, under the section Physical/Skin/Incision/Wound Patient 5 had a Stage 2 on left toe (unspecified toe) with pink wound tissue present, no drainage, undermining absent and surrounding tissue intact, a Stage 2 pressure ulcer on right toe (unspecified toe) with pink wound tissue present, no drainage, undermining absent and surrounding tissue intact, and Stage 2 pressure ulcer on sacral area with pink wound tissue present, no drainage, undermining absent and surrounding tissue intact. The visiting nurses did not provide accurate wound assessment that included wound measurements. During a review of Patient 5’s clinical notes dated 1/2/2025 to 1/19/2025 there was an inaccurate wound assessment that indicated inconsistent wound sites and number of pressure ulcers with no measurements of wound during home visit. During a review of Patient 5’s clinical notes dated 1/19/2025, indicated Patient 5 had a Stage 2 left toe ulcer with no measurement, beefy red wound tissue, absent tunneling and no drainage, a Stage 2 right toe pressure ulcer stating the wound healed, and a Stage 2 sacrum pressure sore indicating the wound healed. During a review of Patient 5’s plan of care indicated the agency did not develop a plan of care for wound care management. During an interview with the Director of Patient Care Services (DPCS) on 8/1/2025, at 9:30 a.m., the DPCS stated there was no wound measurement done by the visiting nurse all throughout the time Patient 5 was on service. The DPCS also stated that weekly measurement should have been done since it was identified in initial assessment and there was no plan of care to identify weekly measurement of the wound. During an interview with the ADM on 8/5/2025, at 1 p.m., when asked where the specific location of Patient 5’s Stage 2 left toe pressure ulcer and Stage 2 right toe pressure ulcer, the ADM stated that she could not find any documented evidence in the patient’s electronic chart. During a review of the HA’s policy and procedure entitled” Wound Care”, revised dated 1/9/2023, indicated Initial documentation will include location, size, stage, depth, presence or absence of drainage, description of any drainage, description of surrounding tissue and any discomfort to the patient. When a wound is initially identified, the interdisciplinary team will be consulted and physician’s order for treatments obtained. Orders will be implemented and treatments either performed by the hospice nurse or by the caregiver following training by the nurse. The skilled nurse will observe the wound weekly and will document according to the individualized plan of care and the patient’s specific goals including location, description of drainage, wound surface and surrounding tissue. During a review of the undated HA’s policy and procedure, titled “The Plan of Care,” the policy and procedure indicated that a written, individualized, patient and family/caregiver plan of care would be established and maintained for everyone admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care.”

“Based on observation, interview and record review, the hospice agency (HA) failed to maintain an accurate, current medication profile for two of 23 sampled patients (Patient 13 and Patient 16). This failure has the potential in placing the patient at risk for medication errors and adverse drug reactions. B. During a record review of Patient 16’s medical record titled “Patient Information,” the record indicated that HA admitted Patient 16 on 6/1/2025 with medical diagnoses that included arteriosclerotic cardiovascular disease (ASCVD, the buildup of fats, cholesterol and other substances in and on the artery walls), Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities), and cerebral vascular accident (CVA, stroke, loss of blood flow to a part of the brain). During a record review of Patient 16’s Face Sheet, the review indicated that the memory care facility admitted Patient 16 on 7/28/2025 with diagnoses that included adult failure to thrive, Alzheimer’s disease, and stroke. During a review of Patient 16’s Active Orders, the review indicated that on 6/20/2025, the physician ordered Magnesium Oxide 400 mg (milligrams- metric unit of measurement, used for medication dosage and/or amount) daily by mouth as a supplement. During a review of Patient 16’s Visit History dated 7/28/2025, the review indicated that the hospice nurse would reconcile Patient 16’s medications at home or in the facility with hospice orders each visit. During a review of Patient 16’s clinical notes dated 7/28/2025, the review indicated that the hospice nurse visited Patient 16 in the memory care facility on the day of admission and reconciled Patient 16’s medications with the facility’s medication technician (MT 1). During a medication reconciliation performed in the facility with the hospice registered nurse (RN 1) and MT 1 on 7/31/2025 at 12:15 p.m., the medication on hand was Magnesium Oxide 500 mg instead of 400 mg. During an interview with MT 1 on 7/31/2025 at 12:35 p.m., MT 1 stated that the hospice nurse who came to the facility on 7/28/2025 did not do a medication reconciliation with her. During an interview with the Director of Patient Care Services (DPCS) on 8/1/2025 at 8:55 a.m., the DPCS stated that when a patient transfers to another facility from home, the hospice nurse immediately goes to the facility to write orders, reconcile medications with the MT, provide teaching to the staff, and collaborate the plan of care with the facility. The DPCS stressed the importance of the hospice nurse performing this reconciliation to ensure that all medications match the physician’s order. During a review of Patient 13’s “Personal Information”, indicated a start of care (SOC) date of 7/19/2025, with a primary diagnosis of cerebrovascular accident (CVA- a stroke that occurs when blood flow to the brain is interrupted, causing brain damage)During a review of Patient 13’s POC/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 7/19/2025, indicated the frequency of visits for skilled nurse (SN) one to two visits per week plus two PRN (pro re nata, “as needed”) visits for assessments, comfort measures, and symptoms management) and Hospice Aide (HA) to visit once a week for personal care, home making, and to promote comfort. A review of Patient 13’s Active Orders dated 7/22/2025, indicated to administer Clonidine 0.2 mg (milligrams) one tab every 8 hours for hypertension, to hold if systolic blood pressure is less than 160. During a home visit on 7/31/2025, at 12:30 p.m., with RN 1, Patient 13 was observed lying in bed alert and oriented x 4 (person, place, time, and event). RN 1 was observed providing wound treatment at Patient 13’s Stage 2 left buttocks pressure ulcer with no drainage present. During a review and observation of Patient 13’s medications at home, there was a bottle of Clonidine with a label to administer 0.2 mg (milligrams) one tab every 8 hours for hypertension, to hold if systolic blood pressure is less than 160. On 7/31/20254, at 1:30 p.m., during an interview with Caregiver 1, she stated she does not administer the Clonidine medication to Patient 13 every 8 hours daily. She further stated she only administers the Clonidine medication if the patient’s blood pressure reading is high like 190/100. During an interview and concurrent record review on 8/1/2025, at 2 p.m., with the Administrator, Patient 13 ’s medical record (in general), the ADM stated the visiting nurse should have checked all the patient’s prescribed medications during visits. During a review of the hospice agency’s policy and procedure titled, “Medication Profile”, revised November 2022, indicated patients receiving medications administered by the hospice will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications.”

“Based on observation, interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to develop an individualized written Plan of Care (POC, a document that maps out needs and services supplied for a Medicare patient facing a terminal illness, as well as the patient’s family/caregiver) that identified significant changes of the patient’s wound status, and update the identified changes in the comprehensive assessment for three of 23 sampled patients (Patient 5, Patient 13 and Patient 17).Patient 5 had a stage 2 pressure ulcer of right toe, stage 2 pressure ulcer of left toe, and stage 2 pressure ulcer of sacral coccyx. There was no care plan developed for these identified pressure ulcers.Patient 13 had an existing Stage 2 left buttocks pressure ulcer; there was no care plan developed for wound care management.For Patient 17 had an existing Stage 4 sacral pressure ulcer; there was no care plan developed for wound care management. This deficient practice placed the wound at risk for slow wound healing leading to wound complication, pain and discomfort to these terminally ill patients. a. During a review of Patient 13’s “Personal Information”, indicated a start of care (SOC) date of 7/19/2025, with a primary diagnosis of cerebrovascular accident (CVA- a stroke that occurs when blood flow to the brain is interrupted, causing brain damage).During a review of Patient 13’s POC/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 7/19/2025, indicated the frequency of visits for skilled nurse (SN) one to two visits per week plus two PRN (pro re nata, “as needed”) visits for assessments, comfort measures, and symptoms management) and Hospice Aide (HA) to visit once a week for personal care, home making, and to promote comfort. There was no documented evidence the HA had developed a POC for wound management to promote healing. A review of Patient 13’s Active Orders dated 7/22/2025, indicated to provide wound care treatment to Stage 2 left buttocks pressure ulcer as follows: to clean with wound spray, pat dry, apply Zinc Oxide and cover with Optifoam dressing. During a home visit on 7/31/2025, at 12:30 p.m., with RN 1, Patient 13 was observed lying in bed alert and oriented x 4 (person, place, time, and event). RN 1 was observed providing wound treatment at Patient 13’s Stage 2 left buttocks pressure ulcer with no drainage present. On 8/1//2025, at 1 p.m., during an interview with the Administrator (ADM), the ADM stated there was no plan of care developed for wound care management to promote proper healing. During a review of the HA’s policy and procedure, titled “The Plan of Care,” revised November 2021, the policy and procedure indicated that a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. b. During a review of Patient 17’s “Personal Information”, indicated a start of care (SOC) date of 1/10/2025, with a primary diagnosis of congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should). During a review of Patient 17’s POC/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 7/30/2025, indicated the frequency of visits for skilled nurse (SN) one to two visits per week plus two PRN (pro re nata, “as needed”) visits for assessments, comfort measures, and symptoms management) and Hospice Aide (HA) to visit once a week for personal care, home making, and to promote comfort. There was no documented evidence the HA had developed a POC for wound management to promote healing. During a home visit on 8/1/2025, at 1:50 p.m., with RN 1, Patient 17 was observed lying in bed alert and oriented x 4 (person, place, time, and event). RN 1 was observed providing wound treatment at Patient 17’s Stage 4 coccyx pressure ulcer with measurements of 3.8 centimeters (cm) in length by 1.9 cm in width by 0.3 cm in depth with no drainage nor odor. On 8/1//2025, at 1:20 p.m., during an interview with the Administrator (ADM), the ADM stated there was no plan of care developed for wound care management for Patient 17. c. . During a review of Patient 5’s “Personal Information”, indicated a start of care (SOC) date of 1/2/2025, with a primary diagnosis of breast cancer. During a review of Patient 5’s POC/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 1/22/2025, indicated the frequency of visits for skilled nurse (SN) one to two visits per week plus three PRN (pro re nata, which means “as needed”) visits for assessments, comfort measures, and symptoms management) and Hospice Aide (HA) to twice a week for personal care, home making, and to promote comfort. During a record review of Patient 5’s clinical records indicated that in the initial assessment dated 1/4/2025, under the section Physical/Skin/Incision/Wound Patient 5 had a Stage 2 on left toe (unspecified toe) with pink wound tissue present, no drainage, undermining absent and surrounding tissue intact, a Stage 2 pressure ulcer on right toe (unspecified toe) with pink wound tissue present, no drainage, undermining absent and surrounding tissue intact, and Stage 2 pressure ulcer on sacral area with pink wound tissue present, no drainage, undermining absent and surrounding tissue intact. The visiting nurses did not provide accurate wound assessment that included wound measurements. During a review of Patient 5’s clinical notes dated 1/2/2025 to 1/19/2025 there was an inaccurate wound assessment that indicated inconsistent wound sites and number of pressure ulcers with no measurements of wound during home visit. During a review of Patient 5’s clinical notes dated 1/19/2025, indicated Patient 5 had a Stage 2 left toe ulcer with no measurement, beefy red wound tissue, absent tunneling and no drainage, a Stage 2 right toe pressure ulcer stating the wound healed, and a Stage 2 sacrum pressure sore indicating the wound healed. During a review of Patient 5’s plan of care indicated the agency did not develop a plan of care for wound care management. During an interview with the Director of Patient Care Services (DPCS) on 8/1/2025, at 9:30 a.m., the DPCS stated there was no wound measurement done by the visiting nurse all throughout the time Patient 5 was on service. The DPCS also stated that weekly measurement should have been done since it was identified in initial assessment and there was no plan of care to identify weekly measurement of the wound. During an interview with the ADM on 8/5/2025, at 1 p.m., when asked where the specific location of Patient 5’s Stage 2 left toe pressure ulcer and Stage 2 right toe pressure ulcer, the ADM stated that she could not find any documented evidence in the patient’s electronic chart.”

“Based on observation, interview, and record review, the hospice agency (HA) failed to ensure prescribed medications including over the counter medications and supplements [CVS Vitamin B12 (a dietary supplement), Vitamin D3 (a dietary supplement), Megestrol Acetate (used to treat advanced cancer)], Sucralfate suspension (to treat stomach ulcers), and Ativan (to treat anxiety) were available for consumption for one of 23 sampled patients (Patient 16). This failure had the potential to compromise the health and safety of Patient 16. During a review of Patient 16’s medical record titled Patient Information, the record indicated that HA admitted Patient 16 on 6/1/2025 with medical diagnoses that include arteriosclerotic cardiovascular disease (ASCVD, the buildup of fats, cholesterol, and other substances in and on the artery walls), Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities), and cerebral vascular accident (CVA, stroke, loss of blood flow to a part of the brain). During a review of Patient 16’s clinical notes dated 6/5/2025, the POC/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) summary indicated that the HA will provide regular education necessary for patient’s care, will monitor patient’s condition and provide needed care, will coordinate care with other IDGs, and will fix/update the patient’s care plan. During a review of Patient 16’s Active Orders, the review indicated the following active medications:1. CVS Stool softener 100 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount).2. Ibuprofen 200 mg.3. Polyethylene Glycol 3350 17 grams (gm, metric unit of measurement used for medication dosage and/or amount).4. CVS Vitamin B12 1000 micrograms (mcg, metric unit of measurement used for medication dosage and/or amount).5. Vitamin D3 capsule 25 mcg.6. Megestrol Acetate 400 mg/10 milliliters. 7. Sucralfate suspension 1gm/10 milliliters.8. Ativan tablet 0.5 mg. During a review of Patient 16’s Charts/Clinical Notes dated 7/28/2025, the review indicated that the hospice nurse visited Patient 16 in the memory care facility on the day of admission (7/28/2025) and reconciled Patient 16’s medications with the facility’s medication technician (MT 1). During a medication reconciliation performed in the facility with the hospice registered nurse (RN 1) and MT 1 on 7/31/2025 at 12:15 p.m., five prescribed medications (CVS Vitamin B12 1000 mcg, Vitamin D3 capsule 25 mcg, Megestrol Acetate 400mg/ 10 milliliters, Sucralfate suspension 1 gm/10 milliliters, and Ativan 0,5 mg) were not available for patient use. During an interview with MT 1 on 7/31/2025 at 12:35 p.m., MT 1 stated that the hospice nurse who came to the facility on 7/28/2025 did not do a medication reconciliation with her and five prescribed medications (CVS Vitamin B12 1000 mcg, Vitamin D3 capsule 25 mcg, Megestrol Acetate 400mg/ 10 milliliters, Sucralfate suspension 1 gm/10 milliliters, and Ativan 0,5 mg) that were listed in the active medication list were not available. During an interview with the Director of Patient Care Services (DPCS) on 8/1/2025 at 8:55 a.m., the DPCS stated that when a patient transfers to another facility from home, the hospice nurse immediately goes to the facility to write orders, reconcile medications with the MT, provide teaching to the staff, and collaborate the plan of care with the facility. The DPCS stressed the importance of the hospice nurse performing this reconciliation to ensure that all medications are unexpired, available, and have clear prescription labels for administration. During a review of the facility’s policy titled “Pharmaceuticals, Medical Supplies, and Durable Equipment” effective 12/2/2008, the policy indicated that the hospice staff will make pharmaceuticals available to hospice patients.”

“Based on record review and interview, the Hospice agency failed to coordinate services in accordance with the POC for 2 of 23 sample patients (Patient 5 and Patient 17) by failing to:Coordinate and provide hospice aide services as ordered on the POC.Ensure nursing services assessed the patient’s pressure ulcers that included pressure ulcer measurements for Patient 5 and Patient 17. This failure has the potential risk to impede the healing process causing deterioration and or worsening of the pressure ulcers leading to infection, pain, and discomfort of the hospice patients. Patients 5’s Personal Information Record, the record that indicated the SOC was 1/2/2025, with diagnosis of breast cancer with metastasis(spreading) to the brain and liver.Patient 5’s initial Plan of Care (POC) dated 1/2/2025, included hospice aide to visit patient two times a week for 13 weeks. Hospice aid was to provide personal care, assistance with activities of daily living (ADLs), and complete bed baths. RN supervisory visit to be conducted every 14 days. During a telephone interview with Patient 5’s family care giver (FCG) on 7/30/2025, at 10 am., stated that when RN 2 came out to do the initial assessment on 1/2/2025. RN 2 informed them Patient 5 would receive a hospice aide to assist with hygiene; however, Patient 5 had to call the hospice agency multiple times due to the hospice aid had visited Patient 5 and needed assistance. FCG also stated Patient 5 did not receive any diapers from the HA and had to request multiple times and ended up buying them.FCG stated Patient 5 passed away on 1/20/2025 and it took the HA 3 weeks of being on service, and Patient 5 only received one visit from a hospice aide. FCG stated she wrote a bad review of the hospice agency on YELP (a user -generated assessments of business, products, or services, typically found on the Yelp platform) before she was contacted by the HA via phone and a grievance with the hospice agency was initiated.The HA’s grievance log was requested and review of the Grievance/Concern form for Patient 5, dated 3/31/25 & 4/1/25, indicated multiple concerns from FCG.During an interview with the TEAM Leader on 8/4/2025, in the HA, she stated there was missed coordination and that the staff responsible for ensuring scheduling disciplines visits and DME supplies did not do, and they were let go.During an interview and concurrent review of Patient 5’s clinical record with the ADM., In the HA’s regarding the grievance 8/4/2025, at 1pm, she stated that all the concerns in the grievance were identified and that somehow there was lost communication/coordination and that some staff identified in that grievances had to be let go. The ADM. Stated they implemented new policies. The ADM. Was apprised of the RN’s documentation indicating supervisory visit of hospice aide when there was no hospice aide present or providing care. Review of the HA’s policy and procedure titled, “ Hospice aide services dated 12/02/2008, stipulates, “ All Hospice Aide services will be provided in accordance with the Plan of treatment and will be supervised by a registered. A review of the same policy and procedure under: A designated RN or RN Supervisor or Team Leader or Director of Patient Care Services will:5) The RN will visit the home site/nursing facility every 14 days when hospice aide services are being provided in order to assess/supervise that the services are being given in accordance with the POC.”

“Based on interview, record review, and document review, the hospice agency (HA) failed to ensure provision of Certified Home Health Aide (CHHA) services was implemented as ordered on the plan of care (POC) for 1 or 23 sample Patients (Patient 5). This deficient practice resulted in the patient not receiving personal care services for three consecutive weeks, despite repeated request from the family leading to unmet hygiene needs. During a review of Patients 5’s Personal Information Record, the record that indicates patient 5’s SOC was 1/2/2025, with diagnosis of breast cancer with metastasis(spreading) to the brain and liver.The initial Plan of Care (PO) dated 1/2/2025, instructed the hospice aide to visit patients two times a week for 13 weeks. CHHA was to provide personal care, assistance with activities of daily living (ADLs), and complete bed baths. Recor review of CHHA notes indicated no hospice aide had visited Patient 5 except one time on 1/16/2025. The POC also indicated CHHA supervisory visit to be conducted by a registered Nurse (RN) at least every 14 days. Review of the RN visit notes dated, 1/4/2025, documented that a hospice aide was present and care was being observed during the supervisory visits. This was the last documented CHHA supervisory visit done by the RN. During a telephone interview with RN 1 on 8/4/2024, at 2 pm in the HA’s conference room. The DPCS confirmed no CHHA visited Patient 5 except one time on 1/16/2025. Review of the HA’s policy and procedure titled, “Hospice aide services dated 12/02/2008, stipulates, “All Hospice Aide services provided by the hospice will be provided in accordance with the Plan of treatment and will be supervised by a registered.A review of the HA’s policy and procedure under: A designated RN or RN Supervisor or Team Leader or Director of Patient Care Services will:5) The RN will visit the home site/nursing facility every 14 days when hospice aide services are being provided in order to assess/supervise that the services are being given in accordance with the POC.”

“Based on observation, interview and record review, the hospice agency failed to ensure the clinical records contained documented evidence of an accurate clinical information and completed wound assessments for three of 26 sampled patients (Patient 5, Patient 13, and Patient 17). The deficient practice resulted in the lack of coordination of patients’ clinical information and continuity of care services provided to these patients certified to receive the hospice benefits. b. During a review of Patient 17’s “Personal Information”, indicated a start of care (SOC) date of 1/10/2025, with a primary diagnosis of congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should). During a review of Patient 17’s POC/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 7/30/2025, indicated the frequency of visits for skilled nurse (SN) one to two visits per week plus two PRN (pro re nata, “as needed”) visits for assessments, comfort measures, and symptoms management) and Hospice Aide (HA) to visit once a week for personal care, home making, and to promote comfort. During a record review of Patient 17’s Initial Clinical Note Visit dated 1/11/2025, identified Patient 17 had a Stage 2 (partial thickness skin loss appearing as a shallow, open ulcer with red or pink wound bed) pressure ulcer on the coccyx (tailbone), the visiting nurse however, failed to perform a comprehensive wound assessment that included location, size, stage, depth, presence or absence of drainage, description of any drainage, description of surrounding tissue and any discomfort to the patient. There was no documented evidence the visiting nurse provided wound treatment during the visit. A review of Patient 17’s Clinical Notes from dates 1/13/2025 through 1/30/2025, indicated there was no wound assessment and wound treatment provided to Stage 2 pressure ulcer. From 1/13/2025 through 2/27/2025, the visiting nurses conducted home visits to Patient 17’s residence but failed to document an accurate wound assessment. A review of Patient 17’s Supplemental order dated 1/30/2025, indicated to provide wound care treatment to Stage 2 coccyx pressure ulcer as follows: to clean with normal saline, pat dry, apply Zinc ointment with Optifoam dressing. A review of Patient 17’s Routine visit note dated 2/25/2025 indicated RN 1 identified Patient 17’s left buttock Stage 3 (full thickness skin loss) measuring 5 cm in length by 5 cm in width. A review of Patient 17’s Supplemental Order notes indicated that there was no wound treatment order found for the patient’s newly identified Stage 3 left buttocks pressure ulcer. A review of Patient 17’s physician’s order was reviewed. The Administrator (ADM) confirmed the hospice staff did not inform the physician to obtain a wound treatment order until 1/30/2025. During a review of Patient 17 plan of care indicated the hospice staff did not develop a plan of care for wound management. The clinical note dated 3/4/2025, indicated the wound at sacral/coccyx area had progressed from Stage 2 to Stage 4 (full thickness skin and tissue loss exposing bone, muscle or tendon). There was no documented evidence the comprehensive assessment of the wound was performed by the hospice staff. A review of Patient 17’s Supplemental order dated 1/30/2025, indicated to provide wound care at Stage 4 coccyx pressure ulcer as follows: to clean with normal saline, pat dry, apply Xeroform and Bordered dressing every day or as needed for soiling. During a concurrent interview and record review on 8/1/2025 at 10:30 AM, of Patient 17’s physician’s order was reviewed. The Administrator (ADM) confirmed the hospice staff did not obtain a wound treatment order until 1/30/2025. The ADM stated that the progression of the pressure ulcer can be avoided if wound was assessed correctly and coordinated with the physician for proper treatment. The ADM stated that the hospice nurses should perform wound measurements during home visits to track the progression of the wound, identify potential complications, and ensure appropriate treatment. During a home visit on 8/1/2025, at 1:50 p.m., with RN 1, Patient 17 was observed lying in bed alert and oriented x 4 (person, place, time, and event). RN 1 was observed providing wound treatment at Patient 17’s Stage 4 coccyx pressure ulcer with measurements of 3.8 centimeters (cm) in length by 1.9 cm in width by 0.3 cm in depth with no drainage nor odor. On 8/1/2025, at 2:30 p.m., during an interview with RN 1, stated he was assigned to Patient 17 from March to June 2025, and during those visits, RN 1 measured Patient 17 coccyx pressure ulcer once. RN 1 stated he should have measured Patient 17’s wound once every week every visit according the POC. During a concurrent interview and record review on 8/5/2025 at 12:40 p.m., with the director of patient care services (DPCS), when she was asked if the physician was not notified about the patient with a newly identified Stage 3 pressure ulcer, the DPCS stated she could not find any documentation to show the physician was notified. a. During a review of Patient 13’s “Personal Information”, indicated a start of care (SOC) date of 7/19/2025, with a primary diagnosis of cerebrovascular accident (CVA- a stroke that occurs when blood flow to the brain is interrupted, causing brain damage). During a review of Patient 13’s POC/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 7/19/2025, indicated the frequency of visits for skilled nurse (SN) one to two visits per week plus two PRN (pro re nata, “as needed”) visits for assessments, comfort measures, and symptoms management) and Hospice Aide (HA) to visit once a week for personal care, home making, and to promote comfort. A review of Patient 13’s Active Orders dated 7/22/2025, indicated to provide wound care treatment to Stage 2 left buttocks pressure ulcer as follows: to clean with wound spray, pat dry, apply Zinc Oxide and cover with Optifoam dressing. During a home visit on 7/31/2025, at 12:30 p.m., with RN 1, Patient 13 was observed lying in bed alert and oriented x 4 (person, place, time, and event). RN 1 was observed providing wound treatment at Patient 13’s Stage 2 left buttocks pressure ulcer with no drainage present. On 7/31/2025, at 1 p.m., during an interview with RN 1, stated she does wound assessments on every visits and she measures the Stage 2 left buttocks pressure ulcer once a week according the POC. A review of Patient 13’s Clinical Notes from dated 7/24, 7/25,7/28, 7/29/7/30/2025, indicated there was no wound assessment and wound treatment provided to Stage 2 left buttocks pressure ulcer. During a concurrent interview and record review on 8/1/2025 at 10:30 AM, of Patient 13’s physician’s order was reviewed. The ADM stated that the hospice nurses should perform wound measurements during home visits to track the progression of the wound, identify potential complications, and ensure appropriate treatment.”

“Observed in Record Review. In 2 of 14 patient records reviewed, it was noted that the hospice admission RN did not complete the initial assessment within 48 hours after the election of hospice care was completed. For example, in record RRNHV#4 the RN documented the initial assessment on day 7 after the patient signed the election of benefits and there was not an explanation found for the delay in the medical record. In record RRNHV#6 the RN documented the initial assessment on day 3 after the patient signed the election of benefits and there was not an explanation found for the delay in the medical record. This was confirmed with the VP of Clinical Services, Regional Director and Owner present.
”

“Observed in Record Review. In 1 of 14 patient records reviewed, it was noted that the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions. For example, in record RRNHV#6 the nurse documented changing the foley catheter, but there was no documentation in the POC for foley catheter care. Also in RRNHV#6 the nurse documented wound care per orders however there was no wound care included in the POC or supplemental orders. This was confirmed with the VP of Clinical Services and Regional Director present .”

“Observed in Record Review. In 9 of 14 patient records reviewed, it was noted that care was not provided according to hospice plan of care. For example, in record RRHV#3 the aide visits were ordered 2 times a week and visits were documented 1 time a week throughout the care with no reason given. In record RRHV#4 the aide visits were ordered 2 times a week and during one week only 1 visit was documented with no reason given. In record RRNHV#3 the aide visits were ordered 3 times a week and visits were documented 2 times a week with no reason provided. In record RRNHV#8 the aide visits were ordered 2 times a week and during 4 weeks only 1 visit was documented with no reason provided. Also in RRNHV#8 the spiritual counselor was ordered 1-2 times a month and in 1 month the SC documented 4 regular visits with no reason provided. In record RRNHV#7 the nurse visits were ordered 1-2 times a week and the nurse documented visits with 17 days, 34 days, 20 days, 8 days and 28 days between the visits with no documentation of the reason for the multiple missed visits. In record RRNHV#5 the nurse visits were ordered 1-2 times a week and during the first months of care the nurse documented visits with 53 days and 7weeks between visits, missing multiple visits with no documented reason for the missed visits. In record RRNHV#9 the nurse visits were ordered 1-2 times a week and during the past 2 months 1 week there is no documentation of a nurse visit or reason for no visit. In record RRNHV#10 the aide visits were ordered 2 times a week and in the past 2 months 3 visits were missed with no documentation of reason for missed visits. In record RRNHV#2 the POC stated the patient was to use oxygen 4 liters per nasal cannula and the nurse documented the patient used 3 liters with no documentation of a change in plan. This was confirmed with the VP of Patient Services, the Regional Director and the Owner present.
”

“Observed in Patient Home. In 2 of 4 home visits conducted, it was noted that the staff failed to perform hand hygiene per organizational policy. For example, during home visit RRHV#3 the nurse entered the bag multiple times without performing hand hygiene and worked with the computer without performing hand hygiene. The organization’s ‘Nurse Bag Technique and Trunk Supplies’ policy stated that hand hygiene was to be performed prior to entering the bag and prior to using the computer or phone. For example, during home visit RRHV#4 the nurse failed to perform hand hygiene after removing her gloves greater than 3 times during the visit. The organization’s ‘Hand Hygiene’ policy stated that hand hygiene with hand sanitizer was to be performed after removal of gloves. This was confirmed with the Regional Director present. Observed in Patient Home. In 1 of 4 home visits conducted, it was noted that the organization did not implement infection prevention and control activities. For example, during home visit RRHV#1 the nurse dropped a plastic bag on the floor, left it there for a time then picked it up and put it on the coach. Near the end of the visit the nurse needed the items in the bag and picked it up from the coach, opened it and used the items. This was confirmed and discussed with the Regional Director present who stated that the organization had a process for when something fell to the floor and the nurse did not follow the process. Observed in Patient Home. In 1 of 3 home visits conducted, that included staff who brought equipment into the home it was noted that the organization did not implement its infection prevention and control activities. For example, during home visit RRHV#1 the nurse was noted to wipe her equipment with Clorox disinfectant wipes. The packaging stated to remain visibly wet for 4 minutes. The 4 minute wet time was not observed. This was confirmed with the Regional Director present.”

“Observed in Record Review. In 9 of 12 patient records reviewed, that included hospice aide care, it was noted that hospice aide supervision was not done effectively every 14 days. For example, in record RRHV#1 the aide supervision was documented 1 time a month during the past 3 months. In record RRHV#2 aide supervision was documented with 28 days, 15 days and 21 days between documentation. In record RRHV#3 aide supervision was documented with 21 days between documentation. In record RRHV4 aide supervision was documented with 20 days, 16 days and 22 days between documentation. In record RRNHV#3 and RRNHV#8 the supervision was documented timely however it was not effective, it did not reflect that the aide had not followed the POC frequency of visits. In record RRNHV#6 the nurse documented an aide supervision note 5 days before the aide started care. In record RRNHV#9 the supervision was documented with 31 days, and 16 days between documentation. In record RRNHV#10 the supervision was documented timely however it was not effective, it did not reflect that the aide had not followed the frequency order and did not reflect that the aide documented NA for all cares on all visits but 1 for 2 months. This was confirmed with the VP of Clinical Services and the Owner present.
”

“Based on observation, interview, and record review, the hospice agency (HA) failed to ensure the Condition of Participation regarding Initial and Comprehensive Assessment of Patients was met as follows: 1. The Hospice Agency failed to conduct a skin assessment for one of nineteen sampled patients (Patient 7). Refer to L524 2. The Hospice Agency failed to review all medications the patient was taking and update the medication profile with the currently used medications for 2 of 19 sampled patients (Patients 13 and Patient 14). Refer to L530 3. The Hospice Agency failed to ensure the updated comprehensive assessment included wound measurement for one of 19 sampled patients (Patient 1). Refer to L533 The cumulative effects of these systemic practices resulted in the hospice agency failure to ensure to create an individualized plan of care required to meet the patients needs and treatments. p”

“Based on observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live), failed to ensure the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in the Medicare [federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs), for Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) Care Planning, and Coordination of Services was met as follows: 1.The HA failed to develop and revised care plan that included interventions and care goals for two of 19 sampled patients (Patient 1 and Patient 7). For Patient 1, the HA did not develop care plan for wound care and treatment on Patient 1s right shin (the front of the leg below the knee). For Patient 7, the HA did not Patient 7s gastrostomy tube (a tube inserted through the belly that brings nutrition directly to the stomach) and indwelling catheter ( a flexible tube that’s put into your bladder to drain urine). Refer to L545. 2. The HA failed to develop and maintain a system of communication and integration to ensure care and services necessary were being provided for two of 19 sampled patients (Patient 1 and Patient 13) Refer to L554 The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily mandated federal (government) compliance with the IDG, Care Planning, and Coordination of Services to ensure the highest quality of care are provided to the patients are accurately assessed to receive hospice care and services.”

“Based on interview and record review, the hospice agency (HA) failed to ensure The Notice of Information, home instructions, and patient/family/caregiver teachings, for one of nineteen (19) sampled patients (Patient 7) were written, explained, and provided in a language the patient/family member/caregiver could understand. This deficient practice has the potential to result in patient’s, family member’s, and/or caregiver’s lack of understanding of the pertinent information regarding provided care and services that could impact patients quality of care and wellbeing. A review of Patient 7s Patient Information, indicated a start of care (SOC) date of 5/8/2023, with a primary diagnosis of cerebral vascular accident (CVA, an interruption of the blood flow into the brain cells which can cause lasting brain damage, long-term disability, or even death). The Patient Information indicated Patient 7’s primary language was Spanish. A review of Patient 1s “;Physicians Certification for Hospice Benefit” (CTI, a written certification of terminal illness for a six month or less life expectancy), for the first 90 day period from 5/8/2023 to 8/8/2023, indicated a terminal diagnosis of cerebral vascular accident (CVA). During a home visit with the Registered Nurse (RN 1) on 11/1/2023, at 12:30 p.m., a review of Patient 7s hospice folder indicated Informed Consent/Treatment Authorization and Election of Hospice Medicare Benefit/Patient Authorization forms, Notice of Information and all the information/instructions including current medication list, home safety instructions for oxygen use were in English. During an interview with Patient 7s caregiver (CG1) on 11/1/2023, at 12:40 p.m., Spanish-English language interpretation was provided by Patient 7s family member (FM6). CG1 stated she was the primary caregiver for Patient 7 when the Patient 7’s spouse was at work. CG1 stated that she could understand limited English and she would prefer that instructions and teachings provided by the nurse were in Spanish. CG1 stated that FM6 helped with the interpretation when the visiting nurse was here. FM6 stated either him or his brother was present when the hospice nurse visits Patient 7. CG1 stated that no translation services were offered before. During a telephone interview with Patient 7s Family Member (FM5) on 11/1/2023, at 12:40 p.m., FM5 stated she could speak English, but her primary language was Spanish. FM5 stated that Patient 7s primary language was Spanish. FM5 stated she would prefer that home instructions in the hospice folder were written in Spanish language so that both her and CG1 could better understand the forms inside the hospice folder. FM5 stated that she did not remember if the Notice of Information was given in Spanish language, and she was unsure where she placed, but FM5 stated it should be in the hospice folder. FM5 stated that she was unsure if the translation services were offered to them before. During an interview with RN1 on 11/1/2023, at 1:00 p.m., RN1 stated he asked the help of the office staff for language interpretation or sometimes another Spanish speaking nurse to assist with the interpretation. RN1 stated sometimes Patient 7s sons were present and assisted with the interpretation for Patient 7s caregiver. During an interview and concurrent record review of Patient 7’s clinical records with the Director of Patient Care Services Designee (DPCSD) on 11/2/2023, at 11:00 a.m., the DPCSD stated that they should provide documents for Patient 7 and FM5 written in their preferred language so they can fully understand the process. Further review of Patient 7s clinical records indicated the Notice of Information and Election of Hospice Benefits were in Spanish language and were signed by FM5. DPCSD stated that the document was electronically signed by FM5 and was unsure if signed copies were in Patient 7s hospice folder. Patient 7s clinical records indicated no documented evidence that the visiting nurse translated the services that were offered and provided during the visits. The DPCSD stated that visiting nurses should have documented that translation was offered and provided to patients to validate that teachings or pertinent information related to patient care has been understand by patient/family members or caregivers. A review of the hospice agencys policy and procedure titled “;Patient Rights and Responsibilities”, revised on 1/1/2019, indicated that patients will be informed of their rights and responsibilities in a language and manner that they understand. A review of the hospice agencys policy and procedure titled “;Patient/Family/Caregiver Education”, effective date of 12/2/2008, indicated: -All patients and families will receive verbal and as appropriate, written instructions which included availability of assistance in language translation to increase access to care and services. -Patient education may be provided, as available, in a language and at a level the patient can be expected to understand, including the use of special devices, interpreters, and other aides as necessary to meet the patients specialized needs.”

“Based on observation, interview, and record review, the Hospice Agency (HA) failed to conduct an accurate comprehensive assessment for one of nineteen sampled patients (Patient 7): -Patient 7’s gastrostomy tube (G-tube, a tube inserted through the belly that brings nutrition directly to the stomach) for nutrition and Foley catheter (a medical device that helps to drain the urine) were not assessed and identified in the comprehensive assessment. -Patient 7 newly discovered open wound located in the middle back area, near the spine, was not assessed and identified in the assessment for further treatment and intervention. This deficient practice has the potential to result of the Hospice Agency’s failure to identify and address patient’s needs which can cause discomfort and distress and may affect the patient’s health status and wellbeing. A review of Patient 7s Patient Information indicated a start of care (SOC) date of 5/8/2023, with a primary diagnosis of cerebral vascular accident (CVA, an interruption in the flow of blood into the brain cells which can cause lasting brain damage, long-term disability, or even death). A review of Patient 7s “;Physicians Certification for Hospice Benefit” (CTI, a written certification of terminal illness for a six month or less life expectancy), for the first 90 day period from 5/8/2023 to 8/8/2023, indicated a terminal diagnosis of cerebral vascular accident (CVA). During a home visit with the Registered Nurse (RN 1) on 11/1/2023, at 12:30 p.m., Patient 7 was bed bound (confined in bed), was not in an acute distress, and was unable to reposition himself. Patient 7 had a gastrostomy tube (G-tube, a tube inserted through the belly that brings nutrition directly to the stomach) and a Foley catheter (a medical device that helps to drain the urine). During a concurrent interview with RN 1, RN1 stated the Foley catheter was replaced last week. During an observation on 11/1/2023, at 12:30 p.m., RN 1 provided wound treatment to Patient 7s existing wound located in sacro-coccyx (at the bottom of the spine and tailbone area) area. During an observation with RN 1 and CG1, Patient 7 had an open wound approximately measuring three centimeters in width and length. Small amount of dried yellow discharge was noted in the dressing. RN 1 cleansed the wound and applied new dressing. RN 1 did not measure the newly discovered wound. During an interview with RN 1 on 11/1/2023, at 1:00 p.m., RN 1 stated that he should have measured the newly discovered wound as part of his assessment. During an interview with the Director of Patient Care Services Designee (DPCSD) on 11/2/2023, at 11:00 a.m., the DPCSD stated that visiting nurses should have been doing their own assessment of patients skin including any new additional skin findings. DPCSD stated that it was the nurses responsibility to conduct a proper assessment to address patient’s all the skin issues. During a concurrent interview and record review of Patient 7s initial comprehensive assessment with the DPCSD on 11/2/2023, at 11:00 a.m., the DPCSD stated there was no evidence that the nurses documented assessments to identify Patient 7s gastrostomy status, Foley catheter status and the newly discovered wound located at the middle back area near the spine. A review of the hospice agencys policy and procedure titled “;Wound Care”, effective date of 12/2/2008, indicated that when a wound is initially identified, the interdisciplinary team will be consulted and MD orders for treatment obtained. The policy indicated the initial documentation will include location, size, stage, depth, presence or absence of drainage, description of any drainage, description of surrounding tissue, and any discomfort to the patient. A review of the hospice agencys policy and procedure titled “;Plan of Care: Initial and Comprehensive Assessment”, revised on 3/1/2013, indicated the comprehensive assessment must identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process. The policy indicated all the findings during the interview and assessment of needs will be documented in the medical record. The update of the comprehensive assessment must be accomplished by the hospice interdisciplinary group and must consider changes that have taken place since the initial assessment.”

“Based on observation, interview, and record review, the hospice staff failed to review all medications patients were taking and update the medication profile with currently used medications for four out of 19 sampled patients (Patient 7, Patient 8, Patient 13, and Patient 14). This deficient practice had the potential to place these patients at risk for medication errors and adverse drug reactions. a. A review of Patient 13’s “Patient Information” showed that Patient 13 had a start of care (SOC) date of 6/12/23 with a benefit period reviewed from 9/11/23 to 12/9/23 with the diagnosis of Glioblastoma (A malignant tumor affecting the brain or spine) A home visit was conducted with the Registered Nurse (RN) on 11/1/23 at 11:35 a.m., at the patients home. Patient 13’s Family Member 1 (FM1) answered the door and told the RN the patient is outside the patio. Saw patient was sitting directly under the sun outside their patio. She is unable to express herself verbally but is able to communicate using gestures. Patient denied pain at this time. Observed that patient had right side paralysis and right side facial droop. Patient required assistance in walking and was observed to have uneven and unsteady gait. FM1 assisted her to go back inside for the medication review. During the medication review at the same time and date, Family member 1 (FM1) handed id white paper bag that contained the bottles of the patients medications. Observed that the bottles were empty with no caps on. Brivaracetam 75 milligrams (mg- unit of measurement) one tablet twice daily for seizures had no label on it. FM1 stated he transfers all the patients medications in a monthly medical planner. FM1 stated he keeps the empty bottles in the paper bag upon delivery. FM1 also stated that he threw the new bottle for this medication and kept the lid. FM1 stated he marked the bottle cap to remind him that this medication is taken twice daily. During the home visit with the RN on the same date, RN stated she updated the medication profile and can be viewed on her phone. RN only asked FM1 if he needs refills for patient’s medications. Attempted to conduct a record review and interview the Registered Nurse after the home visit to check her medical record, but she went straight to her car and left. b. A review of Patient 14’s “Patient Information” showed that Patient 14 had an SOC date of 10/21/21 with a benefit period reviewed from 10/11/23 to 12/9/23 with the diagnosis of end stage Alzheimer’s disease with progressive dementia (A progressive disease that destroys memory and other important mental functions). During Patient 14’s medication review via telephone with Family member 2 (FM2) on 11/2/23 at 11:00 a.m., FM2 consented via telephone interview to review medications at home and compared with the medication profile of the hospice agency. The following discrepancies were noticed. Haloperidol 0.5 milligrams (mg-unit of measurement) every four hours as needed for agitation was noted in the medication profile. FM2 stated “No she is not using that anymore” Memantine hydrochloride 5 mg 1 tablet daily for dementia is listed on the medication profile. FM2 stated it was discontinued last June or July her doctor. Senna 8.6 mg 1 tablet daily for bowel management is listed on the medication profile. FM2 stated “ no she is not taking that anymore. She goes at a regular basis. During an interview and concurrent record review with the Director of Patient Care Services Designee (DPCSD) on 11/2/23 at 1:18 p.m., DPCSD stated that the medication profile should be reconciled every home visit to assure that what is ordered is being given and what is being given has the correct doctor’s orders. A review of the HA’s policy titled “Orders for Medications and Treatments” revised 10/3/18 indicated When orders are incomplete, illegible or unclear, the prescriber will be contacted for clarification and a new, verbal order written. All medications are reviewed at least every two weeks by a hospice physician to determine the need to modify the dosage or frequency, discontinue the medication or change medications. A review of the HA’s policy titled “Medication Reconciliation” effective 12/2/08 indicated It is the policy of this hospice to provide for safe medication administration through a process of medication reconciliation at the start of care, at the time of changes in levels or settings of care, and when patients are discharged alive either through revocation (patient initiated), change of hospice, or hospice initiated discharges. Medication reconciliation consists of a comparison of those medications ordered for, administered to, or dispensed to the patient while under the care of the organization to those on the list and any discrepancies are resolved. The medication profile or list is updated and kept current throughout the patient’s stay on hospice. New orders are added and discontinued medications are deleted. c. A review of Patient 7s Face sheet indicated a start of care (SOC) date of 5/8/2023, with a primary diagnosis of cerebral vascular accident (or CVA, is an interruption in the flow of blood to cells in the brain which can cause lasting brain damage, long-term disability, or even death). During a home visit with the Registered Nurse (RN 1) on 11/1/2023 at 12:30 p.m., Patient 7 (P7) appears comfortable, in no acute distress, bed bound status, unable to repositioned himself with a gastrostomy tube (is a tube inserted through the abdomen that brings nutrition directly to the stomach) attached into his abdomen and a foley catheter (is inserted into the urethra (is the hollow tube that lets urine, a waste product, leave the body), the tube that carries urine out of the body, it is gently pushed up the urethra until it reaches the bladder, a hole in the bladder end of the tube allows urine to flow out of the bladder, through the urethra and out of the body into the collection bag) in placed, gastrostomy tube site with dry clean dressing with no saturation or drainage observed, foley catheter site is intact with no leakages or bleeding, tube is clean, urine collection bag appears clean with clear yellow urine approximately 400 milliliters (ml), hang at lower side of bed below P7s bladder and above the floor surface. During concurrent review of P7s active medication list with RN 1, the following medications were not available: Ativan 0.5 milligram (mg) Acetaminophen Rectal Suppository 650 mg Atropine Sulfate Ophthalmic Solution 1% Dulcolax Rectal Suppository 10 mg Morphine Sulfate Solution 20mg/milliliters (ml) Zofran Orally Disintegrating Tablet 4 mg During the home visit with the RN1 on the same date, RN1 stated he does medication reconciliation on each of his visit with P7, RN 1 stated that P7s spouse (FM5) declined the medications that were not available. RN 1 stated he did not document that FM5 declined to have the medications for her husband (P7). RN 1 stated that that the missing medications should have been discontinued and removed from the current medication list to avoid confusion. During a telephone interview with FM5 on 11/1/23 at 1:00 p.m., she stated that she declined the missing medications and does not want those to be taken by her husband (P7). d. A review of Patient 8s Face sheet indicated a start of care (SOC) date of 5/23/2022, with a primary diagnosis of Intracranial Hemorrhage (bleeding between the brain tissue and skull or within the brain tissue itself and can cause brain damage). During a home visit with the Registered Nurse (RN 1) on 11/1/2023 at 2:30 p.m., Patient 8 (P8) appears comfortable, in no acute distress, bed bound status, unable to repositioned herself. Patient 8s son (FM7) at bedside and assisted RN 1 to put out all P8s medications on hand. During concurrent review of P8s current medications on hand with RN 1, the following medications were expired and/or missing: Acetaminophen Rectal Suppository 650mg - missing. Atropine Sulfate Ophthalmic Solution 1% - missing. Bisacodyl Rectal Suppository 10 mg – missing. Duoneb Inhaler Solution 0.5-2.5 mg/3ml – expired May 2023. Famotidine tablet 20 mg – missing. Melatonin 3 mg – expired May 2023. Milk of Magnesia suspension 400mg/5ml – missing. Morphine Sulfate Solution 20 mg/ml – missing. Nitroglycerin Sublingual Tablet 0.4mg – missing. Omeprazole capsule 20 mg – missing. Ondasetron Tablet 4mg – expired June 2023. Sorbitol Solution 70% - missing. Sucralfate tablet 1gm (gram) – expired January 2022. During the home visit with the RN1 on the same date, RN1 stated he should be conducting medication reconciliation on each of his visit with P8, RN 1 stated this is his 3rd visit with P8 and he is new to this case. During interview, FM7 stated that these are the only medications his mother (P8) had, FM7 stated that he does not know if there are other medications somewhere in the house as his sister also store the medications, FM7 stated if his mother (P8) needed a refill, he informed the agency about it. During an interview with the Director of Patient Care Services Designee on 11/2/23 at 12:30 p.m., DPCSD stated that visiting nurses should be conducting medication reconciliation on each visit with the patient to ensure that medications are appropriately provided to patients. DPCSD stated that it is important for patients to have medications ready at home for immediate use if patients condition started to decline.”

“Based on interview and record review, the hospice agency (HA) failed to ensure the updated comprehensive assessment included wound measurement for one of 19 sampled patients (Patient 1). This failure had the potential to delay necessary interventions needed to achieve the desired goals for the patient. A review of Patient 1’s “;Patient Information” indicated Patient 1 was admitted on 4/12/2023 with a primary diagnosis of arteriosclerotic cardiovascular disease (the build-up of fats, cholesterol, and other substances in and on the artery walls, causing obstruction of blood flow). A review of Patient 1s Comprehensive Assessment completed by the Registered Nurse 3 (RN 3), dated 5/10/2023, indicated Patient 1 had a non-healing, stage three (3) pressure ulcer [a stage three pressure ulcer extends through the skin into deeper tissue and fat, but does not reach muscle, tendon, or bone] on the right shin (large two bones on the lower leg). A review of Patient 1s Comprehensive Assessment completed by the RN 3, dated 7/3/2023, indicated Patient 1 had a healing, stage three pressure ulcer on the right shin. No wound measurement was documented. A review of Patient 1s Comprehensive Assessment completed by the RN 4, dated 10/4/2023, indicated Patient 1 had a healed wound on the right shin. A review of Patient 1s Comprehensive assessment completed by RN 4, dated 10/26/2023, indicated Patient 1 had a healed wound on the right shin. The updated Comprehensive Assessment on 10/26/2023, indicated the measurement of the pressure ulcer/wound was seven centimeters in length, five centimeters in width, and two centimeters in depth, with no tunneling (a chronic wound that has progressed to form an opening underneath the surface of the skin) or undermining (occurs when significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface). The assessment indicated that wound measurement was to be done weekly. A review of Patient 1s “;Charts/Clinical Notes,” dated 10/26/2023, completed by the RN 4, indicated that Patient 1 had a right shin wound. The clinical note indicated that RN 4 provided wound care as follows: cleansing with normal saline (a mixture of sodium chloride and water that has a number of uses in medicine including cleaning wounds), patting dry, and covering with bordered gauze (a type of wound dressing) per physician order. A review of clinical document for Patient 1, titled “;Physician Order for Change in the Plan of Care,” dated 10/26/2023, indicated the hospice physician had ordered wound care for Patient 1 as follows: - Wound care to right shin, clean with normal saline (a mixture of sodium chloride and water that has a number of uses in medicine including cleaning wounds), pat dry, cover with bordered gauze (a type of wound dressing) daily by facility staff and/or hospice nurse. During an interview and concurrent record review with the Director of patient Care Services Designee (DPCSD) on 11/2/2023 at 1:30 p.m., the DPCSD reviewed the updated comprehensive assessment for Patient 1 for the following dates: 5/10/2023, 7/3/2023, 10/4/2023, and 10/24/2023. The DPCSD stated, “;The updated comprehensive assessment needs to include the wound measurement, so the IDG (Interdisciplinary Group, a team responsible for the holistic care of the hospice beneficiary) can see if there are changes, if treatment needs to be adjusted.” The DPCSD stated that wound measurement was usually done weekly, but it was also determined by the IDG based on the report from the nurse. The DPCSD stated that wound measurement served as the point of reference in determining if a wound was healing appropriately. A review of Patient 1s “;IDG Meeting Summary,” dated 9/5/2023, 9/19/2023, 10/3/2023, 10/17/2023, and 10/31/2023, indicated there was no documented evidence the IDG identified the updated assessment of the wound, the frequency of wound care, treatment, and intervention. A review of the hospice agencys policy, titled “;Plan of Care – Initial and Comprehensive Assessment,” revised 3/1/2013, indicated that update of the comprehensive assessment must include information on the patients progress toward desired outcomes, as well as a reassessment of the patients response to care. The policy indicated that the comprehensive assessment would include data elements that allow for measurement of outcomes.”

“Based on observation, interview, and record review, the HA (agency providing care to terminally ill patients who have six months or less to live) failed to develop and revised care plan based on identified health issues that reflected the interventions and care goals for the management of related health conditions, for two of 19 sampled patients (Patient 1 and Patient 7). For Patient 1, the HA did not develop care plan for wound care and treatment on Patient 1s right shin (the front of the leg below the knee). For Patient 7, the HA did not Patient 7s gastrostomy tube (a tube inserted through the belly that brings nutrition directly to the stomach) and indwelling catheter ( a flexible tube that’s put into your bladder to drain urine). This deficient practice had the potential for Patient 1 and Patient 7 not receiving care and services to maintain the highest practicable physical, mental, and psychosocial well-being of the patients receiving hospice care services. a. A review of Patient 1’s “;Patient Information” indicated Patient 1 was admitted on 4/12/23 with a primary diagnosis of arteriosclerotic cardiovascular disease (the build-up of fats, cholesterol, and other substances in and on the artery walls, causing obstruction of blood flow). A review of clinical document for Patient 1, titled “;Physician Order for Change in the Plan of Care,” dated 10/26/23, indicated the hospice physician had ordered wound care for Patient 1 as follows: - Wound care to right shin, clean with normal saline (a mixture of sodium chloride and water that has a number of uses in medicine including cleaning wounds), pat dry, cover with bordered gauze (a type of wound dressing) daily by facility staff and/or hospice nurse. A review of Patient 1s “;Team Care Plan,” dated 10/31/23, indicated the following interventions for skin/wound: - Collaborate wound care treatment and dressing change with facility nurse. - Provide supplies/equipment to reduce/minimize wound progression and promote comfort. - Use Mepilex (a type of wound dressing) or Optifoam (a type of wound dressing) to prevent skin breakdown. - Provide Optifoam dressings. Upon review of the care plan, dated 10/31/23, there was no documentation of the wound care ordered by the physician for Patient 1 on 10/26/23. During a joint visit with Licensed Vocational Nurse 1 (LVN 1) on 11/1/23 at 10:30 a.m., Patient 1 was observed lying in bed, awake and alert. Patient 1 was observed non-ambulatory (unable to walk), with contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) observed on bilateral upper and lower extremities. On 11/1/23 at 10:50 a.m., observed LVN 1 remove the old dressing on Patient 1s right shin. Observed brownish-yellowish stain on the dressing removed by LVN 1. LVN 1 stated, “;This brown stuff on the dressing is from the Medihoney. The facilitys treatment nurse said theyve been applying Medihoney on the wound.” LVN 1 was then observed cleansing the wound with normal saline, patting it dry, and applying triple antibiotic ointment (an antibiotic medication used to reduce the risk of infections on skin injuries) on the wound. LVN 1 then subsequently covered the wound with a bordered gauze. No wound measurement was observed. During a concurrent interview and record review with LVN 1 on 11/1/23 at 11:05 a.m., LVN 1 acknowledged the physician order regarding wound care for Patient 1 was not in the care plan. LVN 1 stated, “;The office shouldve updated the care plan.” During a telephone interview with LVN 1 on 11/1/23 at 3:49 p.m., when asked regarding how often should wound measurement be taken since Patient 1s care plan did not indicate the frequency, LVN 1 stated, “;Wound measurement is done weekly, only if the wound gets worse. This patients wound is healing appropriately, so it doesnt need to be measured.” During a concurrent interview and record review with the Director of Patient Care Services Designee (DPCSD) on 11/2/23 at 1:30 p.m., the DPCSD reviewed the “;Physician Order for Change in the Plan of Care,” dated 10/26/23, and the “;Team Care Plan,” dated 10/31/23. The DPCSD stated, “;When we get a new order from MD, its documented on clinical notes or assessment, for treatment orders it goes on the plan of care. If its a paper order, that order should be transferred exactly to the plan of care.” When asked about the possible negative outcome if the physician order was not included in the care plan, the DPCSD stated, “;If its not in the care plan, the patient might not get the care or treatment that was ordered for them.” The DPCSD also stated, “;Wound measurement is usually done weekly, but its also determined by the IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) based on the report from the nurse. The frequency then needs to be transferred to the plan of care. Somehow the IDGs for this patient do not include the frequency, but they should have, so that the frequency can be stated in the plan of care.” The DPCSD stated, “;What the nurse said that wound doesnt need to be measured as long as its healing appropriately is not correct. How do you determine if its healing appropriately? You need a point of reference, which is the measurement.” A review of the hospice agencys policy, titled “;Plan of Care – Professional Management of the Hospice Patient,” effective 12/2/08, indicated the hospice is responsible for coordinating the care of the hospice patient, developing, implementing, and overseeing the plan of care and authorizing all services, drugs, and treatments related to the terminal illness. A review of the hospice agencys policy, titled “General Patient Care Policies - Wound Care,” effective 12/2/08, indicated that the skilled nurse would observe the wound weekly and would document according to the individualized plan of care and the patient’s specific goals, including: a). Location, description of drainage, wound surface, and surrounding tissue. b. A review of Patient 7s Face sheet indicated a start of care (SOC) date of 5/8/2023, with a primary diagnosis of cerebral vascular accident (or CVA, is an interruption in the flow of blood to cells in the brain which can cause lasting brain damage, long-term disability, or even death). A review of Patient 7s “;Physicians Certification for Hospice Benefit” (CTI, a written certification of terminal illness for a six month or less life expectancy), for the first 90 day period from 5/8/2023 to 8/8/2023, indicated a terminal diagnosis of Cerebral Vascular accident (CVA). During a home visit with the Registered Nurse (RN 1) on 11/1/2023 at 12:30 p.m., Patient 7 (P7) appears comfortable, in no acute distress, bed bound status, unable to repositioned himself with a gastrostomy tube (is a tube inserted through the abdomen that brings nutrition directly to the stomach) attached into his abdomen and a foley catheter (is inserted into the urethra (is the hollow tube that lets urine, a waste product, leave the body), the tube that carries urine out of the body, it is gently pushed up the urethra until it reaches the bladder, a hole in the bladder end of the tube allows urine to flow out of the bladder, through the urethra and out of the body into the collection bag) in placed, gastrostomy tube site with dry clean dressing with no saturation or drainage observed, foley catheter site is intact with no leakages or bleeding, tube is clean, urine collection bag appears clean with clear yellow urine approximately 400 milliliters (ml), hang at lower side of bed below P7s bladder and above the floor surface. P7 was observed with unopened non-blistered, non-raised red rashes to neck, upper back and groin areas. During interview with RN 1, RN 1 stated that assessment was documented on onset date of 10/5/23 and hospice physician was informed of it for an order. A review of Patient 7s (P7) current Physicians order/Active Medication List,” dated 10/31/23, indicated the hospice physician ordered for Patient 7 as follows: Nystatin External Cream 100000 unit/gram, 1 gram twice a day as needed for rash/fungal infection with a start date of 10/5/23 A review of P7s skilled nursing note dated 10/5/23, indicated an assessment documented by RN 1 of P7s rashes to neck, upper back and groin areas. A concurrent review of P7s clinical records with the Director of Patient Care Services Designee (DPCSD) on 11/2/23, at 11:00 a.m., indicated no care plan formulated for P7s gastrostomy tube status/site, foley catheter status/site and rashes located on neck, upper back and groin areas. During an interview with the DPCSD, she stated that a care plan should have been formulated pertaining to P7s gastrostomy status, foley catheter status and rashes to provide prompt and appropriate care and interventions and to avoid lack of coordination of the plan of care with the patient and other clinicians involved in the patient care and treatment.”

“Based on interview, and record review, the hospice agency failed to develop and maintain a system of communication and integration to ensure care and services necessary were being provided for one of 19 sampled patients (Patient 1). For Patient 1, the HA, did not coordinate with the skilled nursing facility (SNF, where Patient 1s resided), when the SNF providing wound treatment without the physicians order. This deficient practice had the potential for Patient 1’s delayed wound healing and meeting the patient’s care goals. a. A review of Patient 1’s “;Patient Information” indicated Patient 1 was admitted on 4/12/23 with a primary diagnosis of arteriosclerotic cardiovascular disease (the build-up of fats, cholesterol, and other substances in and on the artery walls, causing obstruction of blood flow). A review of clinical document for Patient 1, titled “;Physician Order for Change in the Plan of Care,” dated 10/26/23, indicated the hospice physician had ordered wound care for Patient 1 as follows: - Wound care to right shin, clean with normal saline (a mixture of sodium chloride and water that has a number of uses in medicine including cleaning wounds), pat dry, cover with bordered gauze (a type of wound dressing) daily by facility staff and/or hospice nurse. A review of Patient 1s “;Team Care Plan,” dated 10/31/23, indicated the following interventions for skin/wound: - Collaborate wound care treatment and dressing change with facility nurse. - Provide supplies/equipment to reduce/minimize wound progression and promote comfort. - Use Mepilex (a type of wound dressing) or Optifoam (a type of wound dressing) to prevent skin breakdown. - Provide Optifoam dressings. Upon review of the care plan, dated 10/31/23, there was no documentation of the wound care ordered by the physician for Patient 1 on 10/26/23. During a joint visit at the skilled nursing facility with Licensed Vocational Nurse 1 (LVN 1) on 11/1/23 at 10:30 a.m., Patient 1 was observed lying in bed, awake and alert. Patient 1 was observed non-ambulatory (unable to walk), with contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) observed on bilateral upper and lower extremities. On 11/1/23 at 10:50 a.m., observed LVN 1 remove the old dressing on Patient 1s right shin. Observed brownish-yellowish stain on the dressing removed by LVN 1. LVN 1 stated, “;This brown stuff on the dressing is from the Medihoney. The facilitys treatment nurse said theyve been applying Medihoney on the wound.” LVN 1 was then observed cleansing the wound with normal saline, patting it dry, and applying triple antibiotic ointment (an antibiotic medication used to reduce the risk of infections on skin injuries) on the wound. LVN 1 then subsequently covered the wound with a bordered gauze. A review of Patient 1s medication list, dated 10/31/23, indicated that triple antibiotic ointment or Medihoney (honey-based ointment used to manage burns, arterial ulcers, and surgical wounds) were not ordered by the physician. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 11/1/23 at 11:05 a.m., LVN 1 stated she was not sure why the facility staff applied Medihoney on Patient 1. LVN 1 stated she informed the facility staff that she used triple antibiotic ointment to treat Patient 1s wound instead of Medihoney. When asked if there could be any negative outcome when the patient received a treatment that was not ordered by a physician, LVN 1 stated there could be contraindications with other treatment or medication, and side effects could go unmonitored. On 11/1/23 at 11:35 a.m., a request was made to speak with the facilitys treatment nurse. A facility representative stated the treatment nurse was busy and unavailable for interview. During an interview with the Director of Patient Care Services Designee (DPCSD) on 11/2/23 at 1:30 p.m., the DPCSD stated, “;Its the nurse responsibility to coordinate the care with the facility and to verify that its being done.” The DPCSD also stated that care coordination was important because if care was not coordinated with other care providers, orders such as medications could be given improperly. The DPCSD stated, “;Hospice always needs to know how the facility staff is treating the patient because we have that responsibility.” A review of the hospice agencys policy, titled “;Plan of Care –Interdisciplinary Group, Care Planning, and Coordination of Services,” revised 3/1/13, indicated that the Registered Nurse (RN) Case Manager is responsible for maintaining communication and integration of services whether provided directly or under arrangement and for ensuring the identification of patient needs and serves as an ongoing liaison with all disciplines providing care. b. A review of Patient 13’s “Patient Information” showed that Patient 13 had a start of care (SOC) date of 6/12/23 with a benefit period reviewed from 9/11/23 to 12/9/23 with the diagnosis of Glioblastoma (A malignant tumor affecting the brain or spine) A home visit was conducted with the Registered Nurse (RN) on 11/1/23 at 11:35 a.m., at the patients home. Patient 13’s Family Member 1 (FM1) answered the door and told the RN the patient is outside the patio. Saw patient was sitting directly under the sun outside their patio. She is unable to express herself verbally but is able to communicate using gestures. Patient denied pain at this time. Observed that patient had right side paralysis and right side facial droop. Patient required assistance in walking and was observed to have uneven and unsteady gait. During an interview with FM1 stated that him and the patient enjoy going on cruises four to 5 times a year for their well being. FM1 stated that they are going on a cruise this coming December to Cabo and San Diego for a week. FM1 stated that he tells the nurse and also notifies the agency before they leave. FM1 also stated he makes sure that he brings all the patients medications and whatever she needs for the week long trip. During a concurrent interview and record review with the Director of Patient Care Services Designee (DPCSD) on 11/2/23 at 1:49 p.m., DPCSD stated that if the care is not coordinated with the facility or caregivers, there would be care issues with the patient care. Orders might be given improperly and the hospice always must know how they are treating the patients. DPCSD stated it is the agency’s responsibility for caring for that patient and updating the plan of care. DPCSD stated that the nurse and agency has to verify if they have enough medications and the comfort kit needs to be packed before the trip. DPCSD confirmed that the plan of care for Patient 13 was not updated. DPCSD stated that we need to document in the care plan when they call and the agency cannot confirm that because we dont have any documentation anywhere in the patients clinical record. The expectation is they should update the plan of care for this situation in the electronic medical record (EMR) during the interdisciplinary group meeting (IDG) and post home visit when they need to. A review of the HA’s policy titled “Plan of Care: Interdisciplinary Team Meeting” revised 3/1/13 indicated it is the policy of Roze Room Hospice to conduct an interdisciplinary care plan development, review and update of the comprehensive assessment for every hospice patient no less frequently than every 15 days. All patients at the inpatient level of care or receiving continuous care or respite care will be reviewed weekly. In addition, all new admissions and all deaths will be reviewed at the first conference after the event occurs. Each team member who has conducted an assessment reviews their results and shares their plan. All team members are given the opportunity to give input to others. The home health aide is given the assignment if it has not been given prior to the meeting. Team members will indicate whether the problem is still active or has been solved (outcomes achieved ) and which interventions are being employed. Problems, measurable outcomes and interventions will be revised as needed. Each member of the team will have the opportunity to discuss the patient’s progress toward the established measurable outcomes. A review of the HA’s policy titled “Plan of Care: Initial and Comprehensive Assessment” revised 3/1/13 indicated to provide a comprehensive assessment that includes the medical, nursing, psychosocial, emotional, and spiritual needs of the patient/ family. This assessment will consist of an initial assessment completed by a registered nurse within 48 hours after the election of hospice care (unless the physician, patient or representative requests that it be completed in less than 48 hours) and in-depth assessments including psychosocial, spiritual and bereavement. Additional assessments will be completed as indicated. The comprehensive assessment is updated by the hospice interdisciplinary group in collaboration with the individual’s attending physician when changes occur but no less frequently than every 15 days. The comprehensive assessment must identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process.”

“Based on interview and record review, the hospice agency’s governing body ([designated persons so functioning] assumes full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operations, and continuous quality assessment and performance improvement), failed to ensure that the hospice services meet the accepted professional standards and principles and ensure necessary care was provided consistently for patients who were receiving hospice service (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) and ensure proper management of the hospice, the provision of all hospice services, continuous quality assessment and performance improvement to run the day to day operation of the hospice. This failure resulted in the delay or lack of coordination in the delivery of hospice care and services. A record review of the governing body minutes disclosed the hospice agency’s governing body conducted the last meeting on 1/9/23, discussed and reviewed the preceding year and the general status of corporate affairs as of 12/31/22. The meeting minutes indicated the board of directors convened in order to conduct an annual evaluation and analysis of the effectiveness of administrative practices, policies and procedures during the preceding year and its continuation into the next year. The matter was considered and discussed, and it was unanimously, RESOLVED, under the auspices of the administrator and administrative staff, the program was meeting its goals and its mission effectively with proper policies and procedures in place, as may have been amended during the preceding year, and shall continue on the same course. FURTHER RESOLVED, the organization anticipates and thus authorized unannounced surveys to be conducted by the Joint Commission to evaluate and assess the organization’s hospice and palliative care program. The following issues were: Lease For Office Space Lease continues in effect. New Bank Account or Change of Authorized Signatures Not Applicable Changes in Corporate Insurance Programs Which Required Corporate Approval Not Applicable Copies of New Significant Contracts to Which Corporation is a Party Standard contracts are in force. Corporate Loans, Including Loans to Shareholders Per accounting records Other Significant Corporate Transactions There was no documented evidence the Governing Body meeting minutes included the annual evaluation of the effectiveness of administrative practices, policies and procedures, oversight of the hospice program’s management and fiscal affairs, the quality of care provided, the annual review and evaluation of the organization’s performance in relation to its written statement of mission, purpose and objective, establishing processes for identification, reporting, analysis and prevention of sentinel events and for ensuring the consistent and effective implementation of a mechanism to accomplish these activities. During an interview with the Director of Patient Care Services Designee/Vice President for Operations (DPCSD/VPO) on 11/2/23 at 1:18 pm., stated that they conduct regular governing body meetings, when possible, to discuss hospice care and services, quality assurance and performance improvement (QAPI) etc. as needed. A review of the HA’s policy titled “ Administration- Governing Body” effective 12/2/08 indicated that all members of the Governing Body will complete an initial orientation of Governing Body Authority /Responsibilities and an annual review and evaluation of the organization’s performance in relation to its written statement of mission, purpose and objective. Documentation of all orientation activities will be maintained and filed in the Governing Body meeting minutes. The annual evaluation will include an analysis of the effectiveness of administrative practices, policies and procedures. Governing Body responsibility as defined in applicable State Licensure regulations and the Federal Conditions of Participation for Hospice Agencies. Governing Body responsibility related to this hospice program’s Quality Assessment and Performance Improvement Program. Governing Body responsibility related to the oversight of this hospice program’s management and fiscal affairs, and the quality of care provided. A review of the HA’s policy titled “ Administration-Governing Body: Authority/Responsibility” effective 12/2/08 indicated the Governing Body assumes full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operations, and continuous quality assessment and performance improvement. The governing body creates, maintains and supports a culture of safety and quality throughout the organization. The Governing Body analyses and assesses the effectiveness of their contributions to improving the organization’s performance. The Governing Body is responsible for establishing processes for identification, reporting, analysis and prevention of sentinel events and for ensuring the consistent and effective implementation of a mechanism to accomplish these activities. The Governing Body uses data and information to guide decisions and to understand variation in the performance of processes supporting safety and quality. The Governing Body will assure that policies, procedures and processes address ethical issues and issues prone to conflict. The Governing Body will establish, monitor and provide annual review of the hospice policies and procedures.”