Bristol Hospice-Orange County

“It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient’s attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. THIS IS A CMS CONDITION LEVEL FINDING This CONDITION was not met as evidenced by a review of clinical records, document review and interviews with the Director of Patient Care Services (DPCS) and the Executive Director (ED), which revealed the hospice: Failed to ensure that hospice care and services were provided in accordance with the plan of care to meet the patient’s needs {HCPC.19.I/L543/418.56(b)}; and Failed to ensure that each patient’s individualized written plan of care reflects patient, and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments {HCPC.21.I/L545/418.56(c)}. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.56: IDG, Care Planning, Coordination of Services. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that the hospice organizes, manages, and administers its resources to provide the hospice care and services to patients, families, and caregivers necessary for the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of participation was not met as evidenced by clinical record reviews and interviews with the Director of Patient Care Services (DPCS) , which revealed issues with the hospice organizing, managing and administering its resources to provide the hospice care and services to patients, families, and caregivers in the following area: Failed to ensure the hospice provided care that optimizes comfort and dignity and is consistent with patient and family needs and goals, with the patient’s needs and goals as priority {HSLG.4.I/L650/418.100(a)}. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation CFR 418.100: Organization and administration of services. The impact of this deficiencies could negatively impact the agency’s provision of safe, quality care that meets the needs of patients, families, and caregivers for the palliation and management of the terminal illness and related conditions. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and service from the agency.”

“It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes and reassessment of the patient’s response to care. The assessment update is completed as frequently as the condition of the patient requires, but no less frequently than every 15 days. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that all patients’ clinical records included an update to their comprehensive assessment at least every 15 days. Agency policy #1-014 “Comprehensive Assessment” (dated 05/2020) read in part, “The comprehensive assessment is updated by the interdisciplinary group ... at a minimum of every 15 days ... If no changes are needed, then that must be documented. If there has been a change in the patient’s condition/status, then the comprehensive assessment must be updated.” Agency policy #9-019 “Nursing Care” (dated 09/2024) read in part, “The hospice registered nurse performs the initial assessment and participates in the comprehensive assessments and ongoing updates of the comprehensive assessments ...” Clinical Record 13: The patient, who resided at home, elected the hospice benefit on 03/12/2024 with the diagnosis of primary lateral sclerosis. The plan of care dated 06/10/2024 to 09/07/2024 included orders for the nurse to visit twice a week and the Social Worker to visit once per month. The plan of care from 09/08/2024 to 11/06/2025 included orders for the nurse to visit the patient once a week. The Registered Nurse (RN) documented a visit on 07/26/2024, the next documented nursing visit was an RN visit on 09/01/2024. That was thirty-seven (37) days between nursing visits; 07/26/2024 to 09/01/2024. The RN visit dated 07/26/2024 stated in part, “BLE (bilateral lower extremity) +3 edema, crackles in bilateral bases. SOB (shortness of breath) and O2 (oxygen) managed appropriately by PCG (primary caregiver) ...” There was also a stage 2 pressure ulcer documented on the anterior right medial calf, that had the start date of 03/12/2024, with orders to cleanse the affected area gently with normal saline and to apply a skin protection ointment barrier and to cover with plastic wrap. Re-apply twice a day as needed with the primary caregiver providing wound care per the physician’s order. The Interdisciplinary Group (IDG) meeting, documented on 07/31/2024, included a note by the nurse that included, “Patient (Pt) resting in recliner .... Pt and PCG aware of hospice care and prefer comfort to further hospitalizations. Pt denies any pain at this time. BLE +3 edema, crackles in bilateral bases. SOB and O2 managers appropriately by PCG. Pt eating - PO intake fair. Pt needs 1.5 hours to self-feed.” On 08/14/2024, the IDG met and the nurse included the same note from the IDG on 07/31/2024; (“Patient (Pt) resting in recliner .... Pt and PCG aware of hospice care and prefer comfort to further hospitalizations. Pt denies any pain at this time. BLE +3 edema, crackles in bilateral bases. SOB and O2 managers appropriately by PCG. Pt eating - PO intake fair. Pt needs 1.5 hours to self-feed”). The IDG Meeting on 08/28/2024 did not include any nursing update. The nurse’s updated comprehensive assessment was documented on 07/26/2024 and that nurse’s note was included in the Interdisciplinary Group Meeting on 07/31/2024. During the IDG Meeting on 08/14/2024, the nurse’s note was the same note from the IDG Meeting on 07/31/2024. There was no nursing update included in the IDG on 08/28/2024. It was thirty-two days until the comprehensive IDG assessment was updated during the RN’s visit on 09/01/2024. During a joint clinical record review and interview with the Director of Patient Care Services (DPCS) and the Executive Director (ED) on 12/20/2024, confirmed the gaps in nursing visits that resulted in the Registered Nurse not providing updates to the comprehensive assessment at least every fifteen days.”

“It is required that the hospice designates a registered nurse member of the IDG to ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the Registered Nurse implemented the patient’s plan of care visit frequency orders or documented the missed visit reason in adherence to agency policy. Agency policy #1-027, “Missed Visits” (dated 05/2020) read in part, “Missed visits will be communicated to the Interdisciplinary Group at the IDG Meeting. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record… If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained ... If a visit is missed and not rescheduled, the clinician will notify the IDG and Director of Patient Care Services/Clinical Supervisor of the missed visit and reason for missed visit. Document in the patient’s clinical record ... patient name, date and type of visit that was missed, reason for the missed visit ... “ Clinical Record 12: The patient, who resided at home, elected the hospice benefit on 08/12/2024 with the diagnosis of atherosclerotic heart disease. The plan of care dated 08/12/2024 to 10/10/2024 included orders for the nurse to visit the patient once a week. The patient had documented visits by the Registered Nurse (RN) on 08/12/2024, 08/27/2024, 08/30/2024, and 09/01/2024. There were no nursing visits documented for the weeks of: 08/18/2024 to 08/24/2024, 09/08/2024 to 09/14/2024, and 09/15/2024 to 09/21/2024. The clinical record lacked documentation regarding the reason for the missed visits. Clinical Record 13: The patient, who resided at home, elected the hospice benefit on 03/12/2024 with the diagnosis of primary lateral sclerosis. The plans of care dated 06/10/2024 to 09/07/2024 and 09/08/2024 to 11/06/2024 included orders for the nurse to visit the patient once a week. The Registered Nurse (RN) documented a visit on 07/26/2024; the next nursing visit was documented on 09/01/2024. There were no nursing visits documented for thirty-seven (37) days. The clinical record lacked documentation regarding the reason for the missed visits. Clinical Record 15: The patient, who resided at home, elected the hospice benefit on 05/01/2024 with the diagnosis of malignant neoplasm of the bladder. The plan of care for 05/01/2024 to 07/29/2024 included orders for the nurse to visit the patient three times a week from 05/01/2024 to 05/04/2024. The Registered Nurse (RN) documented visits on 05/01/2024 and 05/02/2024, however there was not a third nursing visit documented, per the orders. The nursing visit frequency beginning 05/05/2024 to 07/29/2024 was twice a week. The weeks of 05/05/2024 to 05/11/2024, 05/12/2024 to 05/18/2024 and 05/19/2024 to 05/25/2024, each had one LVN visit documented. There was no nursing visit documented for the week of 05/26/2024 to 06/01/2024. For the week of 06/02/2024 to 06/08/2024 there was one nursing visit documented. During the week of 06/09/2024 - 06/15/2024, no nursing visit was documented. For the week of 06/23/2024 to 06/29/2024, one LVN visit was documented. The clinical record lacked documentation regarding the reason for the missed visits. During a joint clinical record review, on 12/20/2024, with the Executive Director (ED) and the Director of Patient Care Services (DPCS), the missed visits were confirmed.”

“It is required that each patient’s individualized written plan of care reflects patient, and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review, and interview. In 3 of 19 (19%) clinical records reviewed, the agency did not ensure that the patient’s plan of care was updated with individualized problems, planned interventions, and/or patient and family goals based on assessment findings. Agency policy #1-015 entitled “Ongoing Comprehensive Assessment” (dated 05/2020) read in part, “Based on the assessments, the plan of care - including problems, needs, goals, and outcomes - will be reviewed and updated by the interdisciplinary group members responsible for the case.” Clinical Record 6: The patient, who resided at home, elected the hospice benefit on 11/10/2024 with the diagnosis of chronic obstructive pulmonary disease. In the nursing visit note dated 11/13/2024, the Registered Nurse (RN) documented in part that the “Patient is alert and oriented x3 but exhibits moderate anxiety ...Due to his confusion with his medications, the patient requires assistance to fill his medication box weekly... The patient resides in an RV ... with a service dog. It is requested that the patient not be sent to a facility if their overall condition deteriorates ... It has been requested that the service dog be sent to (friend) ... “ On 11/14/2024, the Social Worker (MSW) documented a phone evaluation that included, “The pt (patient) was very apprehensive ... did not appear to want to speak with MSW in person... The pt was adamant that he is not homeless and does not want to be restricted to one area. He stated that he likes his lifestyle and denied any help ... MSW spoke with RN ... She stated that he needs assistance with food. MSW gave RN copy of local food banks in the area ... Declined further MSW services ...” On 11/27/2024, an Interdisciplinary Group (IDG) Meeting was documented, and no new interventions or goals were documented. The RN noted in part that the “Patient on a nasal cannula receiving 2 L/min presents with anxiety, cyanosis of the lips, shortness of breath (SOB), and multiple episodes of coughing. Provided instruction on how to check if oxygen is being delivered properly and educated the patient on the signs and symptoms of hypoxia. Patient is alert and oriented x3 ...” The Social Worker noted an attempted call and message left for the patient with possible services he may be interested in receiving. On 12/06/2024, the RN documented during their visit, “A bottle of morphine was delivered. The medication box is organized separately from the breathing treatment boxes, and the pillbox is filled. The patient is instructed to store any pill bottles found in the box designated for medications.” The IDG Meeting documented on 12/11/2024 included a note by the RN that stated, “34 bottles of medication were found in the patient’s RV. The medication box was organized separately from the breathing treatment boxes, and the pillbox is filled. The patient is instructed to store any pill bottles found in the box designated for medications...” The plan of care for 11/10/2024 to 02/07/2025, to include the Interdisciplinary Group (IDG) plans of care updates, did not include patient-specific identified problems, goals, or interventions related to medication safety or the use of the weekly pillbox. Furthermore, the nurse had documented that the patient had stated goals for his care to include a desire to avoid facility placement and plans for his service dog after his death, these were not reflected in the patient’s plan of care. Clinical Record 8: The patient, who resided in an assisted living facility, elected the hospice benefit on 02/06/2024 with the diagnosis of Alzheimer’s disease and secondary diagnoses of severe dementia with behavioral disturbance and hallucinations. On 10/01/2024, the nurse documented that the patient “Continues to be confused and disoriented... Patient is yelling at Dr. (name) and calling him names. When speaking to patient, patient is calm and not yelling, then goes back to yelling ... Refused vitals to be taken...” During the RN’s visit on 10/24/2024, she noted, “Per staff, patient is resistant to care becoming extremely aggressive with daily hallucinations and extreme paranoia ... Yells out to her imaginary doctor when she wants to resist care ...” The physician’s certification of terminal illness for the benefit period 10/13/2024 to 12/11/2024 included that the patient experienced “unspecified hallucinations, paranoia ... is aggressive ...” The Interdisciplinary Group Meeting (IDG) on 10/08/2024 included an update by the RN that the patient had “Ongoing symptoms ... increased hallucinations/paranoia ... updates to care plan since last IDT - none..” There was no updated note from the Social Worker. There was an updated Social Worker goal that the client/family would express/exhibit improved coping abilities with the identified problem of client and family coping that included the intervention to assess the acceptance of the terminal illness and encourage client and family to verbalize their feelings. During the IDG Meeting dated 10/23/2024, there was no update from the RN regarding the patient’s behavior or agitation. Updated problems and interventions by the nurse included monitoring the effectiveness of drug therapy, drug reactions, and side effects and assessing and treating agitation per the physician’s order. The Social Worker noted in part, “She was constantly talking to herself, and stated ‘I,’ fine, please get away from me or I will call the FBI ...” During the 12/04/2024 IDG Meeting, the nurse noted that “Per staff, patient is resistant to care becoming extremely aggressive with daily hallucinations and extreme paranoia ... Yells out to her imaginary doctor when she wants to resist care ...” There was an updated intervention for psychosocial support and to assess psychosocial needs. The Social Worker’s interventions to assess the acceptance of the terminal illness and to encourage the client and family to verbalize feelings were discontinued along with the goal that the client/family would express/exhibit improved coping abilities. The plans of care (to include the IDG updates to the plans of care) for benefit periods 10/13/2024 to 12/11/2024 and 12/12/2024 to 02/09/2025 included the medications with their indications (for behaviors), but there were no identified patient-specific goals of care for the treatment of the patient’s paranoia, hallucinations, or aggressive behaviors. Clinical Record 16: The patient, who resided at home, elected the hospice benefit on 08/09/2024 with the diagnosis of atherosclerotic heart disease with a secondary diagnosis of dementia with anxiety and bipolar disorder. The patient died on hospice services on 11/25/2024. During a PRN (as needed) visit by the Registered Nurse (RN) on 08/30/2024, she documented in part that the “Patient was seen for PRN visit after she was taken to hospital. Son reported that pts (patient’s) husband called 911 because she was yelling and throwing things at him. ... she was treated for a panic/anxiety attack. Pt was very upset and aggravated by me visiting. She yelled at me and stated over and over again she did not want me going over to visit. Refused vitals and assessment.” The Interdisciplinary Group Meeting (IDG) on 09/05/2024 included no changed interventions or goals. The RN noted in part, “Ongoing symptoms and changes ... none...” and the Social Worker’s note read in part, “The husband reports that APS (adult protective services) has been involved due to screaming at night and possible neglect during the day. The son .. is DPOA (durable power of attorney) ...” On 09/17/2024, during a routine visit, the RN documented in part, “Patient was visibly agitated by my presence and started yelling ‘I don’t want you here. I did not ask you to come here.’ Patient refused to have all vitals taken and refused assessment - locked herself in the bathroom until I left. Per husband, adult protective services is assisting him in finding placement for the patient ... he is very concerned about not being able to care for pt due to his own declining health.” During the IDG Meeting on 09/19/2024, the Social Worker update read in part that “Called the son. He declined a visit and stated that his mother has been getting very agitated lately with visitors.... he would call MSW to visit as needed... stated he would like a priest to come and give his mother communion.” The RN noted, “Ongoing symptoms and changes ... none.” The Spiritual Care Counselor added, “Spiritual goals of care: comfort, peace, spiritual needs met ... caring interventions implemented: listening, assurance, comfort ...” The RN’s Recertification Assessment, dated 10/03/2024, documented in part, “Pts O2 (oxygen) saturation was at 78% - per husband refuses to wear oxygen - patient did have some gasping when trying to speak... Husband reports pt (patient) has severe anxiety and pain and takes Percocet....” The plans of care (to include the IDG updates to the plans of care) for benefit periods 08/09/2024 to 10/07/2024 and 10/08/2024 to 12/06/2024 did not reflect updates for the patient/family goals of care for the treatment of the patient’s agitation and aggression. The plan of care did not include patient or family goals or interventions related to the involvement of Adult Protective Services (APS). Although the patient’s medication list included oxygen for shortness of breath, no goals of care were identified for the patient’s respiratory compromise. During a joint clinical record review and interview with the Director of Patient Care Services (DPCS) on 12/20/2024, the plan of care findings were confirmed. The DCPS contacted the RN Case Managers and had the nurses update the plans of care for the active clinical records six and eight.”

“It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 13 (8%) applicable clinical records reviewed, in which hospice aide services were accepted, the agency did not ensure that the hospice aide documented the Aide Care Plan interventions as directed by the Registered Nurse. Agency policy #9-020, “Hospice Aide Services” (dated 09/2024) read in part, “Hospice aide assignments, plan of care, and interventions will be documented and included in the patient’s clinical record ... Hospice aides will document care provided in accordance with the hospice aide assignment...” Clinical Record 9: The patient, who resided in a board and care facility, elected the hospice benefit on 08/15/2022 with the diagnosis of Parkinson’s disease and a secondary diagnosis of Alzheimer’s disease. The plans of care for the benefit periods dated 10/03/2024 to 12/01/2024 and 12/02/2024 to 01/30/2025 included orders for the hospice aide to visit the patient four times a week. The Hospice Aide care plan for both benefit periods included an intervention to document the patient’s last bowel movement date. A review of the Hospice Aide visits from 11/04/2024 to 12/13/2024 revealed that the intervention to document the date of the last bowel movement was left blank on each visit. There was also an intervention to notify the nurse if any changes to the patient’s bowels were noted or reported or if the patient had not had a bowel movement in two to three days. This intervention was marked as completed for all the same visits, but no additional information was included. During a joint clinical record review with the Director of Patient Care Services and the Regional Vice President, on 12/19/2024, confirmed that the aide did not document the date of the patient’s last bowel movement as the Aide plan of care interventions directed.”

“It is required that the management and governance of the hospice is responsible to provide care that: optimizes comfort and dignity; and is consistent with patient and family needs and goals, with the patient’s needs and goals as priority. This standard was not met as evidenced by clinical record review, and interview. In 4 of 19 (21%) clinical records reviewed the agency management did not ensure the hospice provided care that was consistent with the patient and family needs and goals, with the patient’s needs and goals as priority. Clinical Record 7: The patient, who resided at home, elected the hospice benefit on 04/12/2024 with the diagnosis of hemiplegia and hemiparesis following a cerebral infarction. During the start of care visit by the Registered Nurse (RN) on 04/12/2024, the nurse documented that the patient had a 14 Fr (French) Foley catheter with a 5-10cc balloon, and that the next catheter change was due on 05/02/2024. Also noted was that the patient was receiving a 600cc bolus via gastric tube (g-tube) every five to six hours. The nurse noted on 09/05/2024 that the patient continued on bolus feeding via g-tube with Boost (six cartons a day), and that the daughter was aware to check for residual and to hold feeding. It was noted that the Foley was draining appropriately. On 09/20/2024, the nurse performed a visit due to the patient pulling out his Foley. She included ...” need Foley 14Fr but didn’t have one; patient urinated during visit...” And on the next nursing visit on 09/26/2024, the nurse documented that the Foley catheter was not to be reinserted. At the time of record review, the clinical record did not include physician orders for a Foley catheter, including size/balloon size, frequency of catheter changes, or orders to discontinue the Foley catheter when it was pulled out by the patient on 09/20/2024 and remained out on 09/26/2024. Additionally, the record did not include orders for the formula for the patient’s gastric tube feedings, no ordered route - via pump or by gravity bolus feedings, no amount of formula, and no directions for checking placement or residuals, with parameters to the family on when to hold the feedings based on the residual amount. The clinical record lacked evidence the hospice provided care consistent with the patient needs. Clinical Record 12: The patient, who resided at home, elected the hospice benefit on 08/12/2024 with the diagnosis of atherosclerotic heart disease. The plan of care dated 08/12/2024 to 10/10/2024 included orders for the nurse to visit the patient once a week. The patient had documented visits by the Registered Nurse (RN) on 08/12/2024, 08/27/2024, 08/30/2024, and 09/01/2024. There was no nursing visits documented for the weeks of: 08/18/2024 to 08/24/2024, 09/08/2024 to 09/14/2024, and 09/15/2024 to 09/21/2024. The clinical record lacked evidence the hospice provided care consistent with the patient needs. Clinical Record 13: The patient, who resided at home, elected the hospice benefit on 03/12/2024 with the diagnosis of primary lateral sclerosis. The plans of care dated 06/10/2024 to 09/07/2024 and 09/08/2024 to 11/06/2024 included orders for the nurse to visit the patient once a week. The Registered Nurse (RN) documented a visit on 07/26/2024 and the next nursing visit was documented on 09/01/2024. There was no nursing visits documented for thirty-seven (37) days. The clinical record lacked documentation regarding the reason for the missed visits. The nurse’s updated comprehensive assessment was documented on 07/26/2024 and that nurse’s note included in the Interdisciplinary Group Meeting on 07/31/2024. During the IDG Meeting on 08/14/2024, the nurse’s note was the same note from the IDG Meeting on 07/31/2024. There was no nursing update included in the IDG on 08/28/2024. It was thirty-two days until the comprehensive IDG assessment was updated during the RN’s visit on 09/01/2024. The RN assessment, dated 07/26/2024, stated in part, “BLE (bilateral lower extremity) +3 edema, crackles in bilateral bases. SOB (shortness of breath) and O2 (oxygen) managed appropriately by PCG (primary caregiver) ...” There was also a stage 2 pressure ulcer documented on the anterior right medial calf, that had the start date of 03/12/2024, with orders to cleanse the affected area gently with normal saline and to apply a skin protection ointment barrier and to cover with plastic wrap. Re-apply twice a day as needed with the primary caregiver providing wound care per the physician’s order. There were no documented wound measurements. Per the clinical record documentation, the next nursing visit (RN or LVN) was documented on 09/01/2024. That equals a 5-week gap from the nursing visit on 07/26/2024 to the next visit on 09/01/2024 without a documented assessment of the patient’s wound. The clinical record lacked evidence the hospice provided care consistent with the patient needs. Clinical Record 15: The patient, who resided at home, elected the hospice benefit on 05/01/2024 with the diagnosis of malignant neoplasm of the bladder. The plan of care for 05/01/2024 to 07/29/2024 included orders for the nurse to visit the patient three times a week from 05/01/2024 to 05/04/2024. The Registered Nurse (RN) documented visits on 05/01/2024 and 05/02/2024, however there was not a third nursing visit documented, per the orders. The nursing visit frequency beginning 05/05/2024 to 07/29/2024 was twice a week. The weeks of 05/05/2024 to 05/11/2024, 05/12/2024 to 05/18/2024 and 05/19/2024 to 05/25/2024, each had one LVN visit documented. There was no nursing visit documented for the week of 05/26/2024 to 06/01/2024. For the week of 06/02/2024 to 06/08/2024 there was one nursing visit documented. During the week of 06/09/2024 - 06/15/2024, there was no nursing visit documented. For the week of 06/23/2024 to 06/29/2024 only one LVN/LPN visit was documented. The clinical record lacked evidence the hospice provided care consistent with the patient needs. During a joint clinical record review and interview with the Director of Patient Care Services (DPCS) on 12/19/2024, it was confirmed that there were no orders in the clinical record for the patient’s foley catheter, to include size and balloon size and frequency of catheter changes. There was also no order to discontinue the foley catheter when it was pulled out by the patient, and the nurse noted that the catheter would not be reinserted. The DPCS also confirmed that there were no orders for the g-tube feeding formula, amount, administration method, or for placement/residual checks with any parameters for when to hold the feeding. Additionally, during the joint clinical record review and interview, on 12/20/2024, the Director of Patient Care Services (DPCS) and the Executive Director (ED) confirmed the gaps in nursing visits.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed the agency did not ensure the clinical records included physician orders. Clinical Record 7: The patient, who resided at home, elected the hospice benefit on 04/12/2024 with the diagnosis of hemiplegia and hemiparesis following a cerebral infarction. During the start of care visit by the Registered Nurse (RN) on 04/12/2024, the nurse documented that the patient had a 14 Fr (French) Foley catheter with a 5-10cc balloon, and that the next catheter change was due on 05/02/2024. Also noted was that the patient was receiving a 600cc bolus via gastric tube (g-tube) every five to six hours. The nurse noted on 09/05/2024 that the patient continued on bolus feeding via g-tube with Boost (six cartons a day), and that the daughter was aware to check for residual and to hold feeding. It was noted that the Foley was draining appropriately. On 09/20/2024, the nurse performed a visit due to the patient pulling out his Foley. She included ...” need Foley 14Fr but didn’t have one; patient urinated during visit...” At the next nursing visit on 09/26/2024, the nurse documented that the Foley catheter was not to be reinserted. At the time of record review, the clinical record did not include physician orders for a Foley catheter, including size/balloon size, frequency of catheter changes, or orders to discontinue the Foley catheter when it was pulled out by the patient on 09/20/2024 and remained out on 09/26/2024. Additionally, the record did not include orders for the formula for the patient’s gastric tube feedings, no ordered route - via pump or by gravity bolus feedings, no amount of formula, and no directions for checking placement or residuals, with parameters to the family on when to hold the feedings based on the residual amount. During a joint clinical record review and interview with the Director of Patient Care Services (DPCS) on 12/19/2024, it was confirmed that there were no orders in the clinical record for the patient’s Foley catheter to include size and balloon size and frequency of catheter changes. There was also no order to discontinue the Foley catheter when it was pulled out by the patient, and the nurse noted that the catheter would not be reinserted. The DPCS confirmed that there were no orders for the g-tube feeding formula, amount, administration method, or for placement/residual checks with any parameters for when to hold the feeding.”