Roze Room Hospice of South Bay

“Based on observation, interview, and record review, the Hospice Agency (HA) failed to meet the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for IDG, Care Planning, and Coordination of Services as follows: a. The HA failed to follow all orders in the individualized Plan of Care (POC [documents the process of identifying a patient’s needs and facilitating complete care and ensures collaboration among nurses, patients, and other healthcare providers]) for six of nineteen samples patients (Patient 1, Patient 6, Patient 7, Patient 12, Patient 15, and Patient 17). (refer to L543) b. The HA failed to include pertinent diagnoses (all known diagnoses) in the plan of care (POC, a written plan that specifies scope, frequency, duration of services and a program of treatment or care) for five of 19 sampled patients (Patient 4, Patient 7, Patient 11, Patient 13, and Patient 17). (refer to L545) c. the HA failed to ensure the physician was notified of the care and services that were not rendered for nine of nineteen sampled patients (Patient 1, Patient 5, Patient 6, Patient 7, Patient 12, Patient 13, Patient 14, Patient 15, and Patient 17). (refer to L555) The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated (written law) compliance with Federal regulation for Care planning, Coordination, Quality of care to ensure the highest quality of care are provided to patients certified to receive the hospice benefits.”

“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 ensure the Conditions of Participation (the terms healthcare organizations must meet in order to participate in federally funded healthcare programs) regarding Organizational Environment was met as follows: 1.The hospice agency failed to provide Volunteer services and documented evidence of Volunteer services being offered to eleven of nineteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 11, Patient 13, Patient 14, and Patient 17. (Refer to L652) The cumulative effect of these systemic practice resulted in the failure of the hospice to deliver statutorily mandated Federal compliance for Organizational environment to ensure highest quality of hospice care and services are provided to all patients certified to receive the benefits.”

“Based on observation, interview and record review the HA failed to ensure seven of nineteen sampled patients (Patient 1, Patient 2, Patient 11, Patient 12, Patient 13 and Patient 16 and Patient 17) hospice staff verbally explained the patient’s rights information on how to lodge complaint regarding care and services provided and were provided written addresses, hotline telephone numbers, and telephone number of the local district office Department. The deficient practice had the potential to result in patients lack of knowledge on how to properly lodge and resolve their complaint to the Department. A. During a record review of Patient 1s Personal Information Sheet, the personal information sheet indicated a start of care (SOC) date of 05/30/2024, with a terminal diagnosis bladder cancer, (occurs when cells in the bladder start to grow without control). During an observation and interview on 1/29/2025 at 10:50 am with RN 1 at Patient 1s residence, the state hotline number could not be located on the HA folder or documents inside. RN 1 stated, “;I am actually not sure where the state hotline number is. I havent seen it myself.” During an interview on 1/29/2025 at 11:55 am with Patient 1s wife, Patient 1s wife stated, “;I am unaware of any number where we can contact the state hotline. If we have complaints we just call the hospice. I didnt know we could call the state.” B. During a record review of Patient 2s Personal Information Sheet, the personal information sheet indicated a start of care (SOC) date of 11/26/2024, with a terminal diagnosis interstitial lung disease, (a group of disorders that cause progressive scarring of lung tissue). During an observation and interview on 1/29/2025 at 11:30 am with RN 2 at Patient 2s residence, the state hotline number could not be located on the HA folder or documents inside. RN 2 stated, “;I have not seen where the state hotline number is. I would actually like to know where that is located in the documents if we have it.” During an interview on 1/29/2025 at 11:35 am with Patient 2s caregiver, Patient 2s caregiver stated, “;I have not seen any state hotline number. We usually will call the hospice if we have issues. I didnt know we could call the State too.” During a record review of HAs policy and procedure titled, “;Patient Rights and Responsibilities” dated July 2011, the policy and procedure indicated, “; the California standards of quality Hospice care 2003 includes additional rights: 5. To be informed by the licensee of the provisions of the law regarding complaints and procedures for registering complaints, confidentiality, including, but not limited to, the address and telephone number of the local district office of the department.” C. A review of Patient 11s “;Personal Information”, document indicated a Start of Care (SOC) date of 9/10/2024, with a primary diagnosis of Congestive Heart Failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a joint home visit on 1/29/2025 at 10:50am with Registered Nurse 3 (RN) at Patient 11s home. Patient 11 was sitting up in recliner chair, wearing a nasal cannula connected to oxygen concentrator at 2l/min, and alert and oriented to self, time, date and location. Patient 11 was observed speaking Spanish. During a concurrent observation and interview on 1/29/2025 at 10:55 am with Patient 11, the HA binder was reviewed. Patient 11’s HA binder indicated the state hotline number could not be located on the binder or the documents inside. Patient 11 stated he did not know about the hotline number, what it was for and where to locate it in the HA binder. D. A review of Patient 12s “;Personal Information”, document indicated a Start of Care (SOC) date of 8/12/2024, with a primary diagnosis of Parkinsons disease ((a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a joint home visit on 1/29/2025 at 12:10pm with RN3 at Patient 12s home, the patient was observed lying on the couch in the living area, with eyes closed, sleeping, with blankets covering patient from neck to her feet, and with noted tremors to patients right and left hand and tremors of the lips. During a concurrent observation and interview on 1/29/2025 at 12:25pm with Patient 12s Son stated he could not locate the state hotline number inside the folder or the documents inside. Patient 12s Son stated not aware of the hotline number and the reason to call it, and did not know where to find it in the folder. E. A review of Patient 13s “;Personal Information”, document indicated a Start of Care (SOC) date of 11/6/2024, with a primary diagnosis of Arteriosclerotic cardiovascular disease (ASCVD- the hardening and thickening of the arteries, the blood vessels that carry blood away from the heart). During a phone interview on 1/31/2025 at 10:42am with Patient 13s Daughter, Patient 13s daughter stated when Patient 13 was admitted to hospice services she did not recall being told about the hotline number. Patient 13s granddaughter further stated she did not know what the hotline number was for, and stated “;it must be somewhere in the packet they provided me, there were too many pages”. F. A review of Patient 16s “;Personal Information”, document indicated a Start of Care (SOC) date of 4/9/2024, with a primary diagnosis of Arteriosclerotic cardiovascular disease (ASCVD- the hardening and thickening of the arteries, the blood vessels that carry blood away from the heart). During a phone interview on 1/31/2025 at 10:51am with Patient 16s granddaughter, Patient 16s granddaughter stated she lives with the patient and is with her 24/7 and hands on with her care. Patient 16s granddaughter further stated she was not aware of the hotline number, where to find it and its reason for calling it. G. A review of Patient 17s “;Personal Information”, document indicated a Start of Care (SOC) date of 9/24/2024, with a primary diagnosis of Congestive Heart Failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a phone interview on 1/31/2025 at 11am with Patient 17s Son, Patient 17s son patient is non-verbal, he is primary caregiver and is with her 24/7 for the last two years. Patient 16s son also stated he was not aware of what the hotline number was and what to call it for and where to find it in the HA folder.”

“Based on observation, interview and record review, the Hospice agency (HA) failed to ensure skilled nurses conducted an ongoing medication reconciliation every visit for two of nineteen sampled patients (Patient 1, Patient 2). The deficient practice had the potential to result in medication error and adverse drug reactions. A. During a record review of Patient 1s Personal Information Sheet, the personal information sheet indicated a start of care (SOC) date of 05/30/2024, with a terminal diagnosis bladder cancer, (occurs when cells in the bladder start to grow without control). During a record review of Patient 1s Medication List, dated 1/28/2025, indicated a list of medications including; Tramadol HCL (pain medication) 50 mg 1 tab daily by mouth as needed for medication pain, Oxygen 2 Liters/ per minute as needed for shortness of breath via Nasal cannula (a device that gives additional oxygen through the nose). During a concurrent observation and interview on 1/29/2025 at 10:30 am with Registered Nurse 1(RN 1) at Patient 1s residence, there was no Tramadol or oxygen concentrator observed. RN 1 stated, “;Patient 1 doesnt usually take Tramadol. He has Tylenol and Morphine here for pain, but I will refill it right now. I am not sure how long Patient 1 has been out of the medication, but this was not reported to me. As for the oxygen concentrator, Patient 1s wife returned it to the agency and said they dont use it. This order was supposed to be removed from the medication list. It wasnt done.” During an interview on 1/29/2025 at 10:40 am with Patient 1s wife at Patient 1s residence, Patient 1s wife stated, “;Patient 1 usually takes the Tramadol every other day and he has been out of the medication since yesterday. As far as the oxygen machine, I gave it back to the hospice because Patient 1 didnt need and wasnt using it.” B. During a record review of Patient 2s Personal Information Sheet, the personal information sheet indicated a start of care (SOC) date of 11/26/2024, with a terminal diagnosis interstitial lung disease, (a group of disorders that cause progressive scarring of lung tissue). During a concurrent observation and record review on 1/29/2025 at 11:45 am with RN 2, the medications listed on Patient 2s Medication List, dated 1/28/2025, did not indicate the following medications Patient 2 had in his residence; Thiamine 100mg (vitamin B1 is a vital micronutrient that helps the body convert food into energy)tab take 1 tab by mouth once a day, multivitamin/ minerals take 1 tablet by mouth once daily, Cholecalciferol 50mcg (vitamin D3 is a fat soluble stirrer that helps the body absorb calcium and phosphorus) take 1 tablet by mouth once daily. During an interview on 1/29/2025 at 12 pm with RN 2, RN 2 stated, “;these are medications Patient 2 receives from his primary physician. I know we should have all these medications listed on his medication profile, this was missed by me. I am supposed to be checking all the medications on every visit.” During an interview on 1/30/2025 at 10:45 am with Director of Patient Care Services, (DPCS), DPCS stated, “;the skilled nurses are supposed to do medication reconciliation every visit.” During a record review of HAs policy and procedure titled, “;Medication Reconciliation” dated July 2011, the policy and procedure indicated, “;3. The medication profile or list is updated and kept current throughout the patient’s day on Hospice. New orders are added and discontinued medications are deleted. 4. At the time of the review of the patient by the Hospice interdisciplinary team, the Hospice medical director or Hospice physician will review the current medication list/profile and may make changes at that time.) During a record review of HAs policy and procedure titled, “;Hospice Staff Visit Routines/Missed Visit” dated July 2011, the policy and procedure indicated, “;Review medications, any special procedures, i.e., catheter care, bowel care, etc..””

“Based on interview and record review, the Hospice Agency (HA) failed to follow the written Plan of Care (POC [documents the process of identifying a patient’s needs and facilitating complete care and ensures collaboration among nurses, patients, and other healthcare providers]) for six of nineteen sample patients (Patient 1, Patient 6, Patient 7, Patient 12, Patient 15, and Patient 17). This deficient practice had the potential to result in Patient 1, Patient 6, Patient 7, Patient 12, Patient 15, and Patient 17 not receiving the needed services and treatments as prescribed by the physician that could affect their health status and well-being. A. During a record review of Patient 1s Personal Information Sheet, the personal information sheet indicated a start of care (SOC) date of 05/30/2024, with a terminal diagnosis bladder cancer, (occurs when cells in the bladder start to grow without control). During a review of Patient 1’s Team Care Plan form dated 5/30/2023, indicated the frequency of visits of skilled nurse visits 1-2 times a week for 8 weeks, and Hospice aid visits 2 times a week for 8 weeks, and the spiritual counselor (SC) to one visit per 1-2 times for three months and one as needed (prn) visit for spiritual crisis. During a concurrent interview and record review on 1/30/2025 at 12:55 pm of Patient 1s clinical record with DPCS, there was no documentation of a skilled nurse visit note for 12/23/2024 and no aid visit on 12/20/2025 and 12/25/2025. DPCS stated, “;the skilled nurse that made the visit never turned in the visit note for this date. RN 4 stopped working at our agency on 1/9/2025. I know not documented not done.” When asked how long nurses have to submit their nursing notes after completion of the visit, DPCS stated, “;I believe its 48 hours. RN 4 never submitted hers.” When asked who is responsible to check to see if visit notes are documented in the system, DPCS stated, “;I am. This was missed.” There was no documented evidence of another skilled nurse visit made for the week of 12/23/2024 to 12/29/2024. For the aid visits, the DPCS stated, “;I see how there is an issue here because the aid documented for12/20/2024 CHHA unable to visit, family notified but there is no further explanation as to if other days were suggested or if the physician was notified. For the aid visit 12/25/2024, it indicates family aware no CHHA due to holiday, okay to wait for next CHHA visit but again, there is no documentation if an alternate visit was suggested and declined within that week or if the physician was notified.” B. During a record review of Patient 6s Personal Information Sheet, the personal information sheet indicated a start of care (SOC) date of 12/20/2024, with a terminal diagnosis atherosclerotic cardiovascular disease. During a review of Patient 6’s Team Care Plan form dated 12/20/2024, indicated the frequency of visits of skilled nurse visits 1-2 times a week for 14 weeks, and hospice aid visits 2 times a week for 13 weeks, MSW (social worker) to visit 1-2 times a month for three months, and the spiritual counselor (SC) to one visit per 1-2 times a for three months and one as needed (prn) visit for spiritual crisis. During a concurrent interview and record review on 1/30/2025 at 1:15 pm., of Patient 6s clinical record with DPCS, there was no documentation of a skilled nurse visit note for 12/20/2024 and1/8/2025. There was no documented evidence that an aid visit was made on 12/25/2024, 01/01/2025, 01/10/2025, and 01/17/2025. DPCS stated, “;the skilled nurse that made the visit never turned in the visit note for those dates. Skilled nurse for 1/8/2025 stopped working at our agency on 1/9/2025. I know not documented not done.” When asked how long nurses have to submit their nursing notes after completion of the visit, DPCS stated, “;I believe its 48 hours.” For the aid visits, the DPCS stated, “;For the hospice aid visit on 12/25/2024 and 01/01/2025, it indicated holiday, facility aware no CHHA, but there was no documentation if an alternate visit was suggested and declined within that week or if the physician was notified. I see how there was an issue here because the aid documented for 01/10/2025 CHHA unable to visit, facility made aware, okay to wait for next CHHA visit, but there was no further explanation as to if other days were suggested or if the physician was notified. Same for 1/17/2025, documented CHHA was unable to visit, facility made aware but there was no documented evidence if an attempt to reschedule was made or if the physician was notified.” D. During a record review of Patient 7s Personal Information Sheet, the personal information sheet indicated a start of care (SOC) date of 1/10/2025, with a terminal diagnosis atherosclerotic cardiovascular disease. During a review of Patient 7’s Team Care Plan form dated 1/10/2025, indicated the frequency of visits of skilled nurse visits 1-2 times a week for 14 weeks, and aid visits 2 times a week for 13 weeks, MSW (social worker) to visit 1-2 times a month for three months, and the spiritual counselor (SC) to one visit per 1-2 times a for three months and one as needed (prn) visit for spiritual crisis. During a concurrent interview and record review on 1/30/2025 at 1:25 pm of Patient 7s clinical record with DPCS, there was no documentation of an aid visit made on 01/16/2025. The note indicated CHHA unable to visit, facility made aware. The DPCS stated, “;Again we have the same issue with Patient 7. The aid did not specify if there was an attempt made to reschedule the visit or if the physician was notified.” During a record review of HAs policy and procedure titled,” Interdisciplinary Group, Care Planning and Coordination of Services”, revised March 2013, the policy and procedure indicated, “;all Hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the Hospice upon the physician’s certification of terminal illness and that includes the scope and frequencies of visits.” The policy and procedure further indicated, “;the hassle will develop and maintain a system of communication and integration to: ensure that care and services are provided in accordance of the POC.” During a record review of HAs policy and procedure titled,” Hospice Staff Visit Routines/Missed Visit”, dated July 2011, the policy and procedure indicated, “;the RN case manager will be notified if any scheduled visits that are not made and the visit will be rescheduled if appropriate. If it is not possible to meet the visit frequencies by rescheduling the visit or sending a replacement staff member, the interdisciplinary team will be notified as will the attending physician of the inability to follow the orders regarding visit frequencies.” D. A review of Patient 12s “;Personal Information”, indicated a Start of Care (SOC) date of 8/12/2024, with a primary diagnosis of Parkinsons disease ((a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a review of Patient 12s medical record titled, Team Care Plan, dated 1/28/2025, indicated an order for visit frequency for the SN 1-2 times a week for 13 weeks, and 4 times as needed (PRN) crisis management visits. Certified hospice aide (CHHA) services twice a week also provided as indicated in the POC. During a concurrent interview and record review on 1/30/2025 at 4:10 pm., with the Director of Patient Care Services (DPCS), Patient 12s Electronic Medical Record (EMR) was reviewed. Patient 12s visit schedule for the month of December 2024 indicated the date of 12/25/2024 had a grey rectangle with the letters AID. The DPCS stated a grey rectangle indicated that the visit for that date was not done and the letters AID stood for Hospice Aide. For the date of 12/25/2024, it further indicated under Notes section, “;holiday, facility aware no CHHA”. Patient 12s visit calendar schedule for the month of December 2024 further indicated for the week of 12/22/2024 to 12/28/2024 there was no documented visit from the hospice aide. The DPCS stated and confirmed there was no visit conducted from the hospice aide the week of 12/22/2024 to 12/28/2024, and it was not in accordance with the Team care plan that stated aide to visit 2 times a week. The DPCS further stated that for the missed hospice aide visit on 12/25/2024, there was no documented evidence the HA offered the patient/family a substitute visits date, time or hospice aide. Patient 12s visit schedule for the month of January 2025 was also reviewed and indicated for the date of 1/1/2025 had a grey rectangle with the letters AID, and for the dates 1/7/2025, 1/9/2025 and 1/21/2025 had a grey rectangle with the letters SN. For the date of 1/1/2025 it further indicated under Notes section, “;holiday, family aware no CHHA visit”. Patient 12s visit calendar for January 2025 further indicated there was no documented hospice aide visit for the week of 1/1/2025 to 1/4/2025. The DPCS stated and confirmed there was no hospice aide visit for the date of 1/1/2025 and the documentation under the notes section did not include if the patient/family was offered a substitute visit date, time or hospice aide. On 1/7/2025 it indicated under Notes section, “;RN visit: visit made, unable to obtain documentation”. Patient 12s EMR did not have documented evidence of an SN routine visit note and assessment for the date of 1/7/2025. The DPCS stated the SN scheduled for that visit had resigned and left the HA and did not submit the home visit note and assessment. The DPCS stated and confirmed there was no documentation of a SN routine visit note and assessment to confirm the visit and the patient was assessed, and stated she is aware if there is no documentation then it was not done. For the date of 1/9/2025 and 1/21/2025 there was no documented evidence in the note section of the reason the visit was not made and if the patient was offered another date, time or staff to substitute for the missed visit. Patient 12s EMR also did not have documented evidence of an SN routine visit note and assessment for the dates of 1/9/2025 and 1/21/2025. The DPCS stated and confirmed that the SN did not document a reason for the missed visits or if the patient was offered to reschedule the visit for another date, time or with another SN. The DPCS also stated and confirmed there was no documented evidence of an SN routine visit note and assessment for the dates of 1/9/2025 and 1/21/2025 in Patient 12s EMR. E. A review of Patient 15s “;Personal Information”, document indicated a Start of Care (SOC) date of 6/28/2024, with a primary diagnosis of Arteriosclerotic cardiovascular disease (ASCVD- the hardening and thickening of the arteries, the blood vessels that carry blood away from the heart). During a review of Patient 15s medical record titled, Team Care Plan, dated 1/29/2025, indicated an order for Visit frequency for the SN 1-2 times a week for 8 weeks, and 3 times as needed (PRN) symptom management- pain crisis, and hospice aide 2 times a week for 8 weeks. During a concurrent interview and record review on 1/30/2025 at 3:36 pm., with the Director of Patient Care Services (DPCS), Patient 15s Electronic Medical Record (EMR) was reviewed. Patient 15s visit calendar for the month of December 2024 indicated the date of 12/23/2024 and 12/25/2024 had a grey rectangle with the letters AID. For the date of 12/23/2024, under the notes section it indicated, “;Family requested CHHA Wed. only” and for the date of 12/25/2024 under the notes section it indicated, “;holiday, facility aware no CHHA”. The DPCS stated and confirmed for the dates of 12/23/2024 and 12/25/2024 there was no hospice aide visit conducted. The DPCS also stated and confirmed there was no documented evidence that the HA offered the patient/family a substitute visits date, time or staff. The DPCS further confirmed Patient15 had one hospice aide visit the week of 12/22/2024 to 12/28/2024 and was not in accordance with Team Care plan that indicated aide to visit 2 times a week. Patient 15s visit calendar for the month of January 2025, indicated the date of 1/1/2025 had a grey rectangle with the letters AID. For the date of 1/1/2025, it further indicated in the calendar under Notes section, “;holiday, family aware no CHHA visit”. Patient 15s January 2025 visit calendar indicated for the week of 1/1/2025 to 1/4/2025, there was one documented hospice aide visit. The DPCS stated and confirmed that the grey rectangle indicated the home visit was not conducted by the hospice aide for the date of 1/1/2025 and there was no documented evidence that the patient/family were offered a substitute visit date, time or hospice aide. The DPCS also stated and confirmed Patient 15 had one hospice aide visit week of 1/1/2025 to 1/4/2025 and was not in accordance with the Team Care Plan for aide to visit 2 times a week. Patient 15s January 2025 visit calendar also indicated for dates of 1/6/2025, and 1/8/2025 had a grey rectangle with the letters SN. The DPCS stated the grey rectangle indicated the visit for that date was not done by the skilled nurse. For the date of 1/6/2025 and 1/8/2025 there was no documented evidence in the note section if the patient was offered another date, time or staff to substitute for the missed visit. Patient 15s EMR also did not have documented evidence of an SN routine visit note and assessment for the dates of 1/6/2025 and 1/8/2025. The DPCS stated and confirmed that the SN did not document if the patient was offered to reschedule the visit for another date, time or with another SN. The DPCS stated that the SN scheduled for the visit date of 1/8/2025 had resigned from the HA and left without submitting patient visit notes and assessments. The DPCS also stated and confirmed there was no documented evidence of an SN routine visit note and assessment for the dates of 1/6/2025 and 1/8/2025 and it was not in accordance with the Team care plan that stated the SN to visit 1-2 times a week. F. A review of Patient 17s “;Personal Information”, document indicated a Start of Care (SOC) date of 9/24/2024, with a primary diagnosis of Congestive Heart Failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Patient 17s medical record titled, Team Care Plan, dated 1/29/2025, indicated an order for Visit frequency for the SN 1-2 times a week for 9 weeks, and 3 times as needed (PRN) symptom management- pain crisis, and Hospice aide 2 times a week for 8 weeks. During a concurrent interview and record review on 1/30/2025 at 4:02pm with the Director of Hospice Care Services (DPCS), Patient 17s Electronic Medical Record (EMR) was reviewed. Patient 17s visit schedule for the month of January 2025 indicated the date of 1/17/2025 had a grey rectangle with the letters AID. The DPCS stated a grey rectangle indicates that the visit for that date was not done and the letters AID stood for Hospice Aide. For the date of 1/17/2025, it further indicated under Notes section, “;CHAA unable to visit, family made aware.” Patient 17s visit calendar schedule for the month of January 2025 further indicated for the week of 1/12/2025 to 1/18/2025 there was one documented visit from the hospice aide. The DPCS stated and confirmed there was only one visit from the hospice aide the week of 1/12/2025 to 1/18/2025, on the date of 1/14/2025, and it was not in accordance with the Team care plan that stated aide to visit 2 times a week. The DPCS further stated that for the missed hospice aide visit on 1/17/2025, there was no documented evidence the HA offered the patient/family a substitute visit date, time or hospice aide.”

“Based on interview, and record review, the Hospice Agency (HA) failed to include pertinent diagnoses (all known diagnoses) in the plan of care (POC, a written plan that specifies scope, frequency, duration of services and a program of treatment or care) for five of 19 sampled patients (Patient 4, Patient 7, Patient 11, Patient 13, and Patient 17). This failure had the potential to result in a lack or delay in delivery of necessary care and services for Patient 4, Patient 7, Patient 11, Patient 13, and Patient 17. A. During a record review of Patient 4s Personal Information Sheet, the personal information sheet indicated a start of care (SOC) date of 10/06/2024, with a terminal diagnosis atherosclerotic cardiovascular disease with co-morbidities which included CVA with right hemiparesis (a cerebrovascular accident, otherwise known as a stroke, which is an damage to the brain from interruption of its blood supply causing weakness on the one side of the body, the right in this case). During a concurrent interview and record review on 1/30/2025 at 1:40 pm., with the DPCS, of Patient 4’s Team Care Plan form dated 1/06/2025, there was no care plan for stroke symptoms and management. The DPCS stated, “;no we dont have a care plan for stoke management for Patient 4. It is important to have care plans for the diagnosis because the care plans are the road map for care skilled nurses provide and in this case, they would provide care for the neurological deficits resulting from the stroke.” B. During a record review of Patient 7s Personal Information Sheet, the personal information sheet indicated a start of care (SOC) date of 1/10/2025, with a terminal diagnosis atherosclerotic cardiovascular disease with co-morbidities which included diabetes mellites- insulin dependent (a chronic autoimmune condition where the body’s immune system mistakenly attacks and destroys the insulin producing beta cells in the pancreas resulting in a lifelong condition where the pancreas makes little or no insulin, which leads to high blood sugar levels) . During a concurrent interview and record review on 1/30/2025 at 1:50 pm., with the DPCS, of Patient 7’s Team Care Plan form dated 1/10/2025, there was no care plan for diabetes management. DPCS stated, “;I see that there is no care plan developed for diabetes management for Patient 7. This is important because the nurses need to make sure the facility knows who is managing and monitoring the blood sugars and making sure the staff know how to correctly monitor track the blood sugar levels. Its also important if the patient declines it can affect her overall nutritional status and overall health and medication might need to be adjusted.” During an interview on 1/30/2025 at 12:25pm with the Director of Patient Care Services (DPCS), the DPCS stated that the Registered Nurse (RN) who does the patients initial home visit will start the care plans based on the patients diagnosis and physical assessment as well as needs and location and will also include the universal care plans for medication management, pain, SOC care plan, and education checklist. The DPCS stated any other SNS that do home visits can also add to the care plans or edit according to their assessment of the patient. The DPCS further stated care plans are a way for SN to monitor and track a patients progress or decline. C. A review of Patient 11s “;Personal Information”, document indicated a Start of Care (SOC) date of 9/10/2024, with a primary diagnosis of Congestive Heart Failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Patient 11s medical record titled, B. Recertification Statement for Second 90-day period dated 12/9/2024, indicated an electronic signature from the Hospice Agencys (HA) Medical Director. The Recertification Statement for Second 90-day period also indicated a narrative that stated, “;Patient has recent hospitalization for CHF exacerbation (worsening) and pain.. Patient continues to decline with increased weakness and fatigue (extreme tiredness) ... Patient has bilateral lower extremities (right and left legs) +2 edema” (there is a slight indentation in the skin that disappears within 15 seconds). During a review of Patient 11s Medication List, with date as of 1/28/2025, the medication list indicated an order for the following: 1. Digoxin 125 micrograms (mcg- measurement of medicine) one tablet daily by mouth for heart rate. 2. Eliquis 5 milligrams (mg- measurement of medicine) one tablet twice a day by mouth for blood thinner. 3. Lasix 40 mg one tablet twice a day by mouth for fluid retention. 4. Metoprolol Succinate Extended Release 24-hour 50 mg one tablet daily by mouth for blood pressure. During a concurrent interview and record review on 1/30/2025 at 12:34pm with the Director of Patient Care Services (DPCS), Patient 11s medical record titled Team Care plan with a date of 1/28/2025 was reviewed. Patient 11s Team Care Plan indicated there was no documented care plan for the management of Patient 11s primary diagnosis of CHF. The DPCS stated and confirmed that Patient 11s Team Care Plan did not have documentation on the management of his primary diagnosis of CHF. The DPCS stated Patient 11 should have had a care for CHF because it is his primary diagnosis and the EMR does have a CHF care plan, but the SN did not check it off to open it. D. A review of Patient 13s “;Personal Information”, document indicated a Start of Care (SOC) date of 11/6/2024, with a primary diagnosis of Arteriosclerotic cardiovascular disease (ASCVD- the hardening and thickening of the arteries, the blood vessels that carry blood away from the heart). During a review of Patient 13s medical record titled, A. Certification Statement for first 90-day period dated 11/6/2024, indicated an electronic signature from the Hospice Agencys (HA) Medical Director and the patients attending physician. The Certification statement for the first 90-day period also indicated a narrative that stated Patient 13s Co-morbidities included Seizure disorder and has had that disorder for the last forty years. During a review of Patient 13s Medication List, with date as of 1/28/2025, the medication list indicated an order for the following: 1. Oxcarbazepine 600 mg 1tablet twice a day by mouth for seizures 2. Depakote delayed release 250 mg 3 tablets twice a day by mouth for seizures During a concurrent interview and record review on 1/30/2025 at 3:48 pm with the Director of Patient Care Services (DPCS), Patient 13s medical record titled Team Care plan with a date of 1/29/2025 was reviewed. The team care plan did not have any documented evidence of a care plan for Patient 13s documented comorbidity of seizure disorder. The DPCS stated and confirmed Patient 13s Team Care Plan did not include a care plan for the management of her seizure disorder. The DPCS stated the EMR does have a care plan for seizure disorder, but it was not checked off by the SN to open it. The DPCS stated it is important to have a care plan for the patients seizure disorder so the visiting Skilled Nurse (SN) will know what signs and symptoms to monitor for, anticipate seizure precautions and monitor its impact on her progression of the disease. E. A review of Patient 17s “;Personal Information”, document indicated a Start of Care (SOC) date of 9/24/2024, with a primary diagnosis of Congestive Heart Failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Patient 17s medical record titled, C. Recertification Statement for 60-day period dated 1/22/2025, indicated an electronic signature from the Hospice Agencys (HA) Medical Director. The Recertification statement for 60-day period also indicated a narrative that stated “;... with a hospice diagnosis of CHF... Patient (Pt) with mild shortness of breath using oxygen (02) intermittently, 2liter/minute via nasal cannula.” During a review of Patient 17s Medication List, with date as of 1/29/2025, the medication list indicated an order for the following: 1. Carvedilol 25 mg 1 tablet twice a day by mouth for high blood reassure 2. Clonidine Hydrochloride (HCL) 0.1mg 1 tablet twice a day by mouth as needed for blood pressure greater than 160 3. Eliquis 2.5mg 1 tablet daily by mouth for blood thinner 4. Lasix 20mg a tablet three times weekly, every Monday, Wednesday and Friday by mouth for edema (swelling In the body caused by too much fluid trapped in the body tissue) 5. Lisinopril 10mg 1 tablet daily by mouth for hypertension (high blood pressure) During a concurrent interview and record review on 1/30/2025 at 12:37pm with the Director of Patient Care Services (DPCS), Patient 17s medical record titled Team Care plan with a date of 1/29/2025 was reviewed. Patient 17s Team Care Plan indicated there was no documented care plan for the management of Patient 17s primary diagnosis of CHF. The DPCS stated and confirmed that Patient 17s Team Care Plan did not have documentation on the management of his primary diagnosis of CHF, and stated there should have been a care plan created for CHF because it is his primary diagnosis. The DPCS stated the EMR does have a CHF care plan, but the SN did not check it off to open it. During a review of the HAs Policy and Procedure (P&P) titled, Plan of Care, Interdisciplinary Group, Planning and Coordination of Services, with a revised date of 3/11/2013, indicated, “;The Plan of care will specify the hospice care and services necessary to meet the patient and family specific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions.” The P&P also indicated “;The content of the plan is to include: interventions to manage pain and symptoms, Diagnoses.””

“Based on interview and record review, the Hospice Agency (HA) failed to ensure the physician was notified of the care and services that were not rendered for nine of nineteen sampled patients (Patient 1, Patient 5, Patient 6, Patient 7, Patient 12, Patient 13, Patient 14, Patient 15, and Patient 17). This failure had the potential to result in patients’ significant changes, including progress or decline in health status will not be coordinated promptly with the physician that could delay intervention, and treatment to these patients certified to receive the hospice benefits. A. During a record review of Patient 1s Personal Information Sheet, the personal information sheet indicated a start of care (SOC) date of 05/30/2024, with a terminal diagnosis bladder cancer, (occurs when cells in the bladder start to grow without control). During a review of Patient 1’s Team Care Plan form dated 5/30/2023, indicated the frequency of visits of skilled nurse visits 1-2 times a week for 8 weeks, and aid visits 2 times a week for 8 weeks, and the spiritual counselor (SC) to one visit per 1-2 times for three months and one as needed (prn) visit for spiritual crisis. During a concurrent interview and record review on 1/30/2025 at 12:55 pm of Patient 1s clinical record with DPCS, there was no documentation of a skilled nurse visit note for 12/23/2024 and no aid visit on 12/20/2025 and 12/25/2025. DPCS stated, “;the skilled nurse that made the visit never turned in the visit note for this date. RN 4 stopped working at our agency on 1/9/2025. I know not documented not done.” When asked how long nurses have to submit their nursing notes after completion of the visit, DPCS stated, “;I believe its 48 hours. RN 4 never submitted hers.” When asked who is responsible to check to see if visit notes are documented in the system, DPCS stated, “;I am. This was missed.” There was no documented evidence of another skilled nurse visit made for the week of 12/23/2024 to 12/29/2024. For the aid visits, the DPCS stated, “;I see how there is an issue here because the aid documented for12/20/2024 CHHA unable to visit, family notified but there is no further explanation as to if other days were suggested or if the physician was notified. For the aid visit 12/25/2024, it indicates family aware no CHHA due to holiday, okay to wait for next CHHA visit but again, there is no documentation if an alternate visit was suggested and declined within that week or if the physician was notified.” B. During a record review of Patient 5s Personal Information Sheet, the personal information sheet indicated a start of care (SOC) date of 11/05/2024, with a terminal diagnosis atherosclerotic cardiovascular disease. During a review of Patient 5’s Team Care Plan form dated 11/05/2024, indicated the frequency of visits of skilled nurse visits 1-2 times a week for 12 weeks, and aid visits 2 times a week for 11 weeks, MSW (social worker) to visit 1-2 times a month for three months, and the spiritual counselor (SC) to one visit per 1-2 times a for four months and one as needed (prn) visit for spiritual crisis. During a concurrent interview and record review on 01/30/2025 at 1:05 pm of Patient 5s clinical record with DPCS, there was no documentation of a skilled nurse visit note for 01/09/2025. DPCS stated, “;the skilled nurse note for 01/09/2025 indicates SN unable to make visit, family okay to wait for visit next week. There is no evidence that the physician was notified of this missed visit.” B. During a record review of Patient 6s Personal Information Sheet, the personal information sheet indicated a start of care (SOC) date of 12/20/2024, with a terminal diagnosis atherosclerotic cardiovascular disease. During a review of Patient 6’s Team Care Plan form dated 12/20/2024, indicated the frequency of visits of skilled nurse visits 1-2 times a week for 14 weeks, and aid visits 2 times a week for 13 weeks, MSW (social worker) to visit 1-2 times a month for three months, and the spiritual counselor (SC) to one visit per 1-2 times a for three months and one as needed (prn) visit for spiritual crisis. During a concurrent interview and record review on 1/30/2025 at 1:15 pm of Patient 6s clinical record with DPCS, there was no documentation of a skilled nurse visit note for 12/20/2024 and1/8/2025. There was no documented evidence that an aid visit was made on 12/25/2024, 01/01/2025, 01/10/2025, and 01/17/2025. DPCS stated, “;the skilled nurse that made the visit never turned in the visit note for those dates. Skilled nurse for 1/8/2025 stopped working at our agency on 1/9/2025. I know not documented not done.” When asked how long nurses have to submit their nursing notes after completion of the visit, DPCS stated, “;I believe its 48 hours.” For the aid visits, the DPCS stated, “;For the aid visit on 12/25/2024 and 01/01/2025, it indicates holiday, facility aware no CHHA, but there is no documentation if an alternate visit was suggested and declined within that week or if the physician was notified. I see how there is an issue here because the aid documented for 01/10/2025 CHHA unable to visit, facility made aware, okay to wait for next fir next CHHA visit, but there is no further explanation as to if other days were suggested or if the physician was notified. Same for 1/17/2025, its documented CHHA unable to visit, facility made aware but there is no documented evidence if an attempt to reschedule was made or if the physician was notified.” D. During a record review of Patient 7s Personal Information Sheet, the personal information sheet indicated a start of care (SOC) date of 1/10/2025, with a terminal diagnosis atherosclerotic cardiovascular disease. During a review of Patient 7’s Team Care Plan form dated 1/10/2025, indicated the frequency of visits of skilled nurse visits 1-2 times a week for 14 weeks, and aid visits 2 times a week for 13 weeks, MSW (social worker) to visit 1-2 times a month for three months, and the spiritual counselor (SC) to one visit per 1-2 times a for three months and one as needed (prn) visit for spiritual crisis. During a concurrent interview and record review on 1/30/2025 at 1:25 pm of Patient 7s clinical record with DPCS, there was no documentation of a aid visit made on 01/16/2025. The note indicated CHHA unable to visit, facility made aware. The DPCS stated, “;Again we have the same issue with Patient 7. The aid did not specify if there was an attempt made to reschedule the visit or if the physician was notified.” During a record review of HAs policy and procedure titled,” Interdisciplinary Group, Care Planning and Coordination of Services”, revised March 2013, the policy and procedure indicated, “;all Hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the Hospice upon the physician’s certification of terminal illness and that includes the scope and frequencies of visits.” The policy and procedure further indicated, “;the hassle will develop and maintain a system of communication and integration to: ensure that care and services are provided in accordance with the POC.” During a record review of HAs policy and procedure titled,” Hospice Staff Visit Routines/Missed Visit”, dated July 2011, the policy and procedure indicated, “;the RN case manager will be notified if any scheduled visits that are not made and the visit will be rescheduled if appropriate. If it is not possible to meet the visit frequencies by rescheduling the visit or sending a replacement staff member, the interdisciplinary team will be notified as will the attending physician of the inability to follow the orders regarding visit frequencies.” E. A review of Patient 12s “;Personal Information”, document indicated a Start of Care (SOC) date of 8/12/2024, with a primary diagnosis of Parkinsons disease ((a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a review of Patient 12s medical record titled, Team Care Plan, dated 1/28/2025, indicated an order for Visit frequency for the SN 1-2 times a week for 13 weeks, and 4 as needed (PRN) crisis management visits and hospice aide to visit 2 times a week. During a concurrent interview and record review on 1/30/2025 at 4:10pm with the Director of Hospice Care Services (DPCS), Patient 12s Electronic Medical Record (EMR) was reviewed. Patient 12s visit schedule for the month of December 2024 indicated the dates of 12/2/204, 12/4/2024, 12/9/2024, 12/18/2024, 12/20/2024, 12/25/2024, and 12/27/2024 had a grey rectangle with the letters AID. Patient 12s December 2024 visit calendar also indicated there was no documented hospice aide visits. The DPCS stated the grey rectangle indicates the home visit was nor conducted for that date by the hospice aide. The DPCS stated and confirmed there was no documented evidence that the physician was made aware of the hospice aide missed visits for all of December 2024 for Patient 12. Patient 12s visit calendar for January 2025 was also reviewed and indicated the dates of 1/1/2025, 1/3/2025, 1/8/2025, 1/10/2025, 1/15/2025 and 1/22/2025 had a grey rectangle with the letters AID and for the dates of 1/7/2025, 1/9/2025 and 1/21/2025 had a grey rectangle with the letters SN. The DPCS stated and confirmed the dates with the grey rectangle indicated the home visit was not conducted, either by the hospice aide (AID) or skilled nurse (SN). The DPCS also stated and confirmed Patient 12s EMR did not have any documented evidence that the physician was notified of the missed visits by the hospice aide or skilled nurse, as it was not in accordance with the Team care plan for the aide to visit 2 times a week and SN 1-2 times a week. F. A review of Patient 13s “;Personal Information”, document indicated a Start of Care (SOC) date of 11/6/2024, with a primary diagnosis of Arteriosclerotic cardiovascular disease (ASCVD- the hardening and thickening of the arteries, the blood vessels that carry blood away from the heart). During a review of Patient 13s medical record titled, Team Care Plan, dated 1/29/2025, indicated an order for Visit frequency for the SN 1-2 times a week for 13 weeks, and 4 as needed (PRN) crisis management visits. Hospice aid (CHHA) twice a week. During a concurrent interview and record review on 1/30/2025 at 3:48pm with the Director of Patient Care Services (DPCS), Patient 13s Electronic Medical Record (EMR) was reviewed. Patient 13s visit schedule for the month of December 2024 indicated the dates of 12/26/2024 and 12/31/2024 had a grey rectangle with the letters AID. Patient 13s visit schedule for January 2025 was also reviewed and indicated the date of 1/7/2025 had a grey rectangle with the letters SN. The DPCS stated and conformed that for the dates 12/26/2026, 12/31/2024 the grey rectangle indicated the home visit was not conducted by the hospice aide, and for the date of 1/7/2025 the grey rectangle also meant home visit was not conducted by the skilled nurse. The DPCS also stated and confirmed Patient 13s EMR did not have any documented evidence that the physician was notified of the missed visits by the hospice aide and skilled nurse, as it was not in accordance with the Team care plan for the aide to visit 2 times a week and SN 1-2 times a week. G. A review of Patient 14s “;Personal Information”, document indicated a Start of Care (SOC) date of 11/5/2024, with a primary diagnosis of Coronary Artery Disease (CAD-a condition in which the arteries that supply blood to the heart become narrowed or blocked). During a review of Patient 14s medical record titled, Team Care Plan, dated 1/29/2025, indicated an order for Visit frequency for the SN 1-2 times a week for 13 weeks, and 4 as needed (PRN) crisis management visits, and hospice aide to visit 2 times a week. During a concurrent interview and record review on 1/30/2025 at 3:29 pm., with the Director of Patient Care Services (DPCS), Patient 14s Electronic Medical Record (EMR) was reviewed. Patient 14s visit schedule for the month of January 2025 indicated the dates of 1/10/2025 and 1/17/2025 had a grey rectangle with the letters AID. The DPCS stated and confirmed the grey rectangle indicated the home visit for that date was not conducted by the hospice aide. The DPCS also stated and confirmed Patient 14s EMR did not have any documented evidence that the physician was notified of the missed visits by the hospice aide, as it was not in accordance with the Team care plan for the aide to visit 2 times a week. H. A review of Patient 15s “;Personal Information”, document indicated a Start of Care (SOC) date of 6/28/2024, with a primary diagnosis of Arteriosclerotic cardiovascular disease (ASCVD- the hardening and thickening of the arteries, the blood vessels that carry blood away from the heart). During a review of Patient 15s medical record titled, Team Care Plan, dated 1/29/2025, indicated an order for Visit frequency for the SN 1-2 times a week for 8 weeks, and 3 as needed (PRN) symptom management- pain crisis. During a concurrent interview and record review on 1/30/2025 at 3:36 pm., with the Director of Patient Care Services (DPCS), Patient 15s Electronic Medical Record (EMR) was reviewed. Patient 15s visit schedule for the month of December 2024 indicated the dates of 12/6/2024 12/16/2024, 12/23/2024 and 12/25/2024 had a grey rectangle with the letters AID. Patient 15s visit schedule for the month of January 2025 indicated the dates of 1/1/25, 1/10/25 with a grey rectangle and the letters AID, and for the dates of 1/6, 1/7 and 1/8 had a grey rectangle with the letters SN. The DPCS stated that the grey rectangle indicated the home visit was not conducted. The DPCS stated and conformed for the dates of 12/6, 12/16/24, 12/23/24, 12/25/24, 1/1/25, 1/6/25, 1/7/25, 1/8/25 and 1/10/25, Patient 15 did not have home visits from the hospice aide or skilled nurse. The DPCS also stated and confirmed Patient 15s EMR did not have any documented evidence that the physician was notified of the missed visits by the hospice aide and SN, in accordance with the Team care plan for the hospice aide to visit 2 times a week and SN to visit 1-2 times a week. I. A review of Patient 17s “;Personal Information”, document indicated a Start of Care (SOC) date of 9/24/2024, with a primary diagnosis of Congestive Heart Failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, resulting in leg swelling). During a review of Patient 17s medical record titled, Team Care Plan, dated 1/29/2025, indicated an order for Visit frequency for the SN 1-2 times a week for 9 weeks, and 3 times as needed (PRN) symptom management- pain crisis, and hospice aide 2 times a week for 8 weeks. During a concurrent interview and record review on 1/30/2025 at 4:02 pm., with the Director of Hospice Care Services (DPCS), Patient 17s Electronic Medical Record (EMR) was reviewed. Patient 17s visit schedule for the month of January 2025 indicated the date of 1/2/2025, 1/7/2025 and 1/17/2025 had a grey rectangle with the letters AID. The DPCS stated a grey rectangle indicated that the visits for those dates were not done and the letters AID stood for Hospice Aide. The DPCS stated and confirmed there was only one visit from the hospice aide the week of 1/12/2025 to 1/18/2025, 1/5/2025 to 1/11/2025 and 1/12/2025 to 1/18/2025. The DPCS also stated and confirmed Patient 17s EMR did not have any documented evidence that the physician was notified of the missed visits by the hospice aide, as it was not in accordance with the Team care plan for the aide to visit 2 times a week.”

“Based on interview and record review the hospice agency failed to provide Volunteer services and documented evidence of Volunteer services being offered to ten of nineteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 13, Patient 14, and Patient 17. The deficient practice had the potential to result in patients not receiving volunteer services as required. A. During a record review of Patient 1s Personal Information Sheet, the personal information sheet indicated a start of care (SOC) date of 05/30/2024, with a terminal diagnosis bladder cancer, (occurs when cells in the bladder start to grow without control). During a phone interview on 1/30/2025 at 9:30 am with Patient 1s wife, she stated, “;We have never been offered volunteer services by the hospice agency, I am not even sure what they can do for me.” During a concurrent record review and interview on 1/30/2025 at 12:11 pm with Director of Patient Care Services (DPCS) of Patient 1s Interdisciplinary Group meeting summary form, dated 06/04/2024, indicated next to volunteer: N/A. DPCS stated, “;it doesnt specify on this form whether Patient 1 was offered volunteer services, it says N/A next to volunteers. We document on this form if the services were offered, and it does not indicate here that they were.” B. During a record review of Patient 2s Personal Information Sheet, the personal information sheet indicated a start of care (SOC) date of 11/26/2024, with a terminal diagnosis interstitial lung disease, (a group of disorders that cause progressive scarring of lung tissue). During a phone interview on 1/30/2025 at 9:45 am with Patient 2, Patient 2 stated, “;I dont remember being offered volunteer services by the hospice agency. they didnt explain to me that the services were available.” During a concurrent record review and interview on 1/30/2025 at 12:18 pm with DPCS of Patient 2s Interdisciplinary Group meeting summary form, dated 12/03/2024, indicated Others: Volunteer/ MT/PT/OT/ST/ Physician/ DPCS stated, “;for Patient 2 its confusing because it says others and different disciplines next to it, it almost seems that he has volunteer services. I think this was just listing all the services offered but after the physician it should have said what services Patient 2 has.” C. During a record review of Patient 3s Personal Information Sheet, the personal information sheet indicated a start of care (SOC) date of 9/30/2024, with a terminal diagnosis congestive heart failure (a chronic condition where the heart is not able to pump blood effectively throughout the body). During a phone interview on 1/30/2025 at 9:50 am with Patient 3s grandchild, Patient 3s grandchild stated, “;I dont remember being offered volunteer services by the hospice agency. Not sure what they can do for Patient 3.” During a concurrent record review and interview on 1/30/2025 at 12:20 pm with DPCS of Patient 3s Interdisciplinary Group meeting summary form, dated 10/08/2024, indicated Vol: blank next to it. DPCS stated, “;for Patient 3 its blank next to the volunteer tab. This was not filled out.” D. During a record review of Patient 4s Personal Information Sheet, the personal information sheet indicated a start of care (SOC) date of 10/06/2024, with a terminal diagnosis atherosclerotic cardiovascular disease (a group of conditions that occur when plaque builds up in the arteries narrowing them and reducing blood flow to vital organs such as the heart, brain, and legs). During a phone interview on 1/30/2025 at 9:55 am with Patient 4s child, Patient 4s child stated, “;I dont remember being offered volunteer services by the hospice agency. They offered a social worker, and a chaplain, but I do not recall volunteer services.” During a concurrent record review and interview on 1/30/2025 at 12:30 pm with DPCS of Patient 4s Interdisciplinary Group meeting summary form, dated 10/08/2024, indicated Others: N/A. DPCS stated, “;for Patient 4 it indicated N/A next to the others tab where we should have documented if volunteer services were offered.” E. During a record review of Patient 5s Personal Information Sheet, the personal information sheet indicated a start of care (SOC) date of 11/05/2024, with a terminal diagnosis atherosclerotic cardiovascular disease. During a phone interview on 1/30/2025 at 10:00 am with Patient 5s child, Patient 5s child stated, “;no, we were not volunteer services by the hospice agency.” During a concurrent record review and interview on 1/30/2025 at 12:35 pm with DPCS of Patient 5s Interdisciplinary Group meeting summary form, dated 11/19/2024, indicated Volunteer/ MT/PT/OT/ST/ Physician-... DPCS stated, “;for Patient 5 its confusing because it says different disciplines next to it, it almost seems that he has volunteer services. I think this was just listing all the services offered but after the physician it should have said what services Patient 5 has.” F. During a record review of Patient 6s Personal Information Sheet, the personal information sheet indicated a start of care (SOC) date of 12/20/2024, with a terminal diagnosis atherosclerotic cardiovascular disease. During a concurrent record review and interview on 1/30/2025 at 12:40 pm with DPCS of Patient 6s Interdisciplinary Group meeting summary form, dated 12/24/2024, indicated Volunteer/ MT/PT/OT/ST/ Physician-N/A. DPCS stated, “;for Patient 6 it says different disciplines and N/A next to it. This is also wrong because its making it seem like none of the services were offered. Does not look like we noted here that volunteer services were offered.” G. During a record review of Patient 7s Personal Information Sheet, the personal information sheet indicated a start of care (SOC) date of 1/10/2025, with a terminal diagnosis atherosclerotic cardiovascular disease. During a concurrent record review and interview on 1/30/2025 at 12:45 pm with DPCS of Patient 7s Interdisciplinary Group meeting summary form, dated 1/14/2025, indicated Volunteer/ MT/PT/OT/ST/ Physician-... DPCS stated, “;again, for Patient 7 its confusing because it says different disciplines and nothing next to it, it almost seems that he has volunteer services. I think this was just listing all the services offered but after the physician it should have said what services Patient 7 has.” During a record review of HAs policy and procedure titled, “;Volunteer Services” dated July 2011, the policy and procedure indicated, “;The HA will provide volunteer services according to the standards defined in the Medicare Conditions of Participation Section 418.78- Volunteers.” H. A review of Patient 13s “;Personal Information”, document indicated a Start of Care (SOC) date of 11/6/2024, with a primary diagnosis of Arteriosclerotic cardiovascular disease (ASCVD- the hardening and thickening of the arteries, the blood vessels that carry blood away from the heart). During a concurrent interview and record review on 1/30/2025 at 3:48pm., with the DPCS, Patient 13s medical record titled, Charts/Clinical Notes: IDG Meeting Summary/Update to Comprehensive Plan of Care for initial date of 11/12/2024 was reviewed. Patient 13s medical record indicated under plan of care section, “;Vol: N/A”. Patient 13s medical record also did not have documented evidence if volunteer services were discussed and offered to the patient. The DPCS stated and confirmed Patient 13s initial IDG indicated under volunteer section “;N/A” for not applicable and stated it is not complete and could have been worded better to say if the volunteer services were offered and if accepted or declined. During a phone interview on 1/31/2025 at 10:42am with Patient 13s Daughter, stated when Patient 13 was signed up for and admitted to the HA, the patient was not offered volunteer services. Patient 13s daughter further stated she was not aware of what volunteer services were and that the HA offered that service. I. A review of Patient 14s “;Personal Information”, document indicated a Start of Care (SOC) date of 11/5/2024, with a primary diagnosis of Coronary Artery Disease (CAD-a condition in which the arteries that supply blood to the heart become narrowed or blocked). During a concurrent interview and record review on 1/30/2025 at 3:29pm with the DPCS, Patient 14s medical record titled, Charts/Clinical Notes: IDG Meeting Summary/Update to Comprehensive Plan of Care for initial date of 11/26/2024 was reviewed. Patient 14s medical record indicated under plan of care section, “;Others” Volunteer/ MT/ PT/ OT/ ST/ Physician”. Patient 14s medical record also did not have documented evidence if volunteer services were discussed and offered to the patient and/or family. Patient 14s medical record titled, Charts/Clinical Notes: IDG Meeting Summary/Update to Comprehensive Plan of Care for initial date of 1/21/2025 was also reviewed and indicated “;Others: Volunteer/ MT/ PT/ OT/ST/ Physician”. Patient 14s medical record Charts/Clinical Notes IDG for the date of 1/21/2025 also indicated there was no documented evidence that the patient and/or family were informed about volunteer services and if the patient/family had accepted or declined them. The DPCS stated and confirmed Patient 14s medical records with date of 11/26/2024 and 1/21/2025 did not indicate if the HA staff had discussed with the patient and/or family about volunteer services and if it was declined or accepted. During a phone interview on 1/31/2024 at 10:24am with Patient 14s daughter, stated she was not aware of the volunteer services offered by the HA, stating “;mm no what is that?”. J. A review of Patient 17s “;Personal Information”, document indicated a Start of Care (SOC) date of 9/24/2024, with a primary diagnosis of Congestive Heart Failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, resulting in leg swelling). During a concurrent interview and record review on 1/30/2025 at 4:02pm with the DPCS, Patient 17s medical record titled, Charts/Clinical Notes: IDG Meeting Summary/Update to Comprehensive Plan of Care for initial date of 1/21/2025 was reviewed. Patient 17s medical record indicated under plan of care section, “;Others: Volunteer/ MT/ PT/ OT/ ST/Physician”. Patient 17s medical record further indicated there was no documented evidence that the SN discussed and offered volunteer services to the patient and/or family and if the patient and/or family accepted or declined the services. The DPCS stated and confirmed Patient 17s medical record reviewed did not have documented evidence that the HA staff educated or offered the patient/family about volunteer services and if it was accepted or declined. During a phone interview on 1/31/2025 at 11am with Patient 17s son, Patient 17s son stated he did not know what volunteer services were, what it offered and stated he never heard or knew that the HA offered volunteer services. Patient 17s son further stated he contracts that type of service, or help “;elsewhere” where he pays them out of pocket and does not receive the volunteer services through the HA.”

“Based on interview and record review the hospice agency failed to ensure skilled nurse documented in clinical record the scheduled visits for five of nineteen sampled patients (Patient 1, Patient 6, Patient 12, Patient 13, and Patient 15). The deficient practice had the potential to result in patients not having accurate and up to date information in the clinical record. A. During a record review of Patient 1s Personal Information Sheet, the personal information sheet indicated a start of care (SOC) date of 05/30/2024, with a terminal diagnosis bladder cancer, (occurs when cells in the bladder start to grow without control). During a review of Patient 1’s Team Care Plan form dated 5/30/2023, indicated the frequency of visits of skilled nurse visits 1-2 times a week for 8 weeks, and aid visits 2 times a week for 8 weeks, and the spiritual counselor (SC) to one visit per 1-2 times for three months and one as needed (prn) visit for spiritual crisis. During a concurrent interview and record review on 1/30/2025 at 12:55 pm of Patient 1s clinical record with DPCS, there was no documentation of a skilled nurse visit note for 12/23/2024. DPCS stated, “;the nurse that made the visit never turned in the visit note for this date. Skilled nurse stopped working at our agency on 1/9/2025. I know not documented not done.” When asked how long nurses have to submit their nursing notes after completion of the visit, DPCS stated, “;I believe its 48 hours. Skilled nurse never submitted hers.” When asked who is responsible to check to see if visit notes are documented in the system, DPCS stated, “;I am. This was missed.” There was no documented evidence of another skilled nurse visit made for the week of 12/23/2024 to 12/29/2024. B. During a record review of Patient 6s Personal Information Sheet, the personal information sheet indicated a start of care (SOC) date of 12/20/2024, with a terminal diagnosis atherosclerotic cardiovascular disease. During a review of Patient 6’s Team Care Plan form dated 12/20/2024, indicated the frequency of visits of skilled nurse visits 1-2 times a week for 14 weeks, and aid visits 2 times a week for 13 weeks, MSW (social worker) to visit 1-2 times a month for three months, and the spiritual counselor (SC) to one visit per 1-2 times a for three months and one as needed (prn) visit for spiritual crisis. During a concurrent interview and record review on 1/30/2025 at 1:15 pm of Patient 6s clinical record with DPCS, there was no documentation of a skilled nurse visit note for 12/20/2024 and 1/8/2025. DPCS stated, “;the nurse that made the visit never turned in the visit note for those dates. Skilled nurse for 1/8/2025 stopped working at our agency on 1/9/2025. I know not documented not done.” When asked how long nurses have to submit their nursing notes after completion of the visit, DPCS stated, “;I believe its 48 hours.” During a record review of HAs policy and procedure titled, “;Entries into Medical Record” revised November 2017, the policy and procedure indicated, “;Documentation in the medical record will be timely, detailed, accurate and reflect the care or services provided. Hospice personnel will document all care/service provided at point of care, or as soon as practical and will synchronize electronically after each documented visit or event, but not less frequently than on the day care is rendered.” C. A review of Patient 12s “;Personal Information”, document indicated a Start of Care (SOC) date of 8/12/2024, with a primary diagnosis of Parkinsons disease ((a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a review of Patient 12s medical record titled, Team Care Plan, dated 1/28/2025, indicated an order for Visit frequency for the SN 1-2 times a week for 13 weeks, and 4 as needed (PRN) crisis management visits. During a concurrent interview and record review on 1/30/2025 at 4:10pm with the Director of Patient Care Services (DPCS), Patient 12s Electronic Medical Record (EMR) was reviewed. Patient 12s visit schedule for the month of January 2025 indicated the dates of 1/7/2025, 1/9/2025, and 1/21/2025 had a grey rectangle with the letters SN. The DPCS stated a grey rectangle indicates that the visit for that date was not done and the letters SN stood for Skilled Nurse. For the date of 1/7/2025, it further indicated a note stating, “;RN visit: Visit made, unable to obtain documentation.” Patient 12s EMR did not have documented evidence of an SN routine visit note and assessment for the date of 1/7/2025. The DPCS stated the SN scheduled for that visit had resigned and left the HA and did not submit the home visit note and assessment. The DPCS stated and confirmed there was no documentation of a SN routine visit note and assessment to confirm the visit and the patient was assessed, and stated she is aware if there is no documentation then it was not done. For the date of 1/9/2025 and 1/21/2025 there was no documented evidence in the note section of the reason the visit was not made and if the patient was offered another date, time or staff to substitute for the missed visit. Patient 12s EMR also did not have documented evidence of an SN routine visit note and assessment for the dates of 1/9/2025 and 1/21/2025. The DPCS stated and confirmed that the SN did not document a reason for the missed visits or if the patient was offered to reschedule the visit for another date, time or with another SN. The DPCS also stated and confirmed there was no documented evidence of an SN routine visit note and assessment for the dates of 1/9/2025 and 1/21/2025 in Patient 12s EMR. D. A review of Patient 13s “;Personal Information”, document indicated a Start of Care (SOC) date of 11/6/2024, with a primary diagnosis of Arteriosclerotic cardiovascular disease (ASCVD- the hardening and thickening of the arteries, the blood vessels that carry blood away from the heart). During a review of Patient 13s medical record titled, Team Care Plan, dated 1/29/2025, indicated an order for Visit frequency for the SN 1-2 times a week for 13 weeks, and 4 as needed (PRN) crisis management visits. During a concurrent interview and record review on 1/30/2025 at 3:48pm with the Director of Patient Care Services (DPCS), Patient 13s Electronic Medical Record (EMR) was reviewed. Patient 13s visit schedule for the month of January 2025 indicated the date of 1/7/2025 had a grey rectangle with the letters SN. The DPCS stated the grey rectangle indicated the visit for that date was not done by the skilled nurse. For the date of 1/7/2025, it further indicated a note stating, “;RN visit: Visit made, unable to obtain documentation.” Patient 13s EMR did not have documented evidence of an SN routine visit note and assessment completed for the date of 1/7/2025. The DPCS stated the SN scheduled for that visit had resigned and left the HA without submitting the home visit note and assessment. The DPCS stated and confirmed there was no documentation of a SN routine visit note, and assessment completed for the date of 1/7/2025 for Patient 13, and stated she is aware if there is no documentation then it was not done. E. A review of Patient 15s “;Personal Information”, document indicated a Start of Care (SOC) date of 6/28/2024, with a primary diagnosis of Arteriosclerotic cardiovascular disease (ASCVD- the hardening and thickening of the arteries, the blood vessels that carry blood away from the heart). During a review of Patient 15s medical record titled, Team Care Plan, dated 1/29/2025, indicated an order for Visit frequency for the SN 1-2 times a week for 8 weeks, and 3 as needed (PRN) symptom management- pain crisis. During a concurrent interview and record review on 1/30/2025 at 3:36pm with the Director of Patient Care Services (DPCS), Patient 15s Electronic Medical Record (EMR) was reviewed. Patient 15s visit schedule for the month of January 2025, indicated the dates of 1/6/2025, and 1/8/2025 had a grey rectangle with the letters SN. The DPCS stated the grey rectangle indicated the visit for that date was not done by the skilled nurse. For the date of 1/6/2025 and 1/8/2025 there was no documented evidence in the note section if the patient was offered another date, time or staff to substitute for the missed visit. Patient 15s EMR also did not have documented evidence of an SN routine visit note and assessment for the dates of 1/6/2025 and 1/8/2025. The DPCS stated and confirmed that the SN did not document if the patient was offered to reschedule the visit for another date, time or with another SN. The DPCS stated that the SN scheduled for the visit date of 1/8/2025 had resigned from the HA and left without submitting patient visit notes and assessments. The DPCS also stated and confirmed there was no documented evidence of an SN routine visit note and assessment for the dates of 1/6/2025 and 1/8/2025 in Patient 15s EMR.”

“Observed in Record Review. In 8 of 10 patient records reviewed, for active hospice patients the plan of care did not include measurable outcomes anticipated from implementing and coordinating the plan of care. For example, in review of the medical record for RRNHV #1 the plan of care included a problem of mobility with a goal that patent/caregiver demonstrates safe, effective use of assistive devices by end of each visit and lacked measurable goals such as patient/caregiver will demonstrate safe transfer techniques from bed to chair or ambulate with walker and assistance from bedroom to kitchen within 2 weeks. Also, for RRNHV #3 the clinical notes from nursing visits documented that the patient had pitting edema of the lower extremities and the plan of care included a problem for Cardiovascular with a goal that patient/caregiver understands management of CV symptoms as evidenced by verbalization within 1 week of onset of new symptoms, however the plan of care was lacking measurable goals such as edema of lower extremities will be reduced by 50% within two weeks with prescribed interventions. This was also observed in review of the medical records for RRNHV #4, RRNHV #5, RRNHV # 6, RRNHV #7, RRNHV #8 and RRNHV #9 where the plan of care goals were not individualized and measurable. This was discussed with and validated with the DPCS and the HCO leadership team. 


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“Observed in Record Review. In 2 of 14 patient records reviewed, the organization had not provided care according to the patient’s individualized plan of care. For RRHV #1 the frequency for the Spiritual Counselor visits were 1-2xmonth however in review of the medical record there was no evidence of a visit to the patient by the Spiritual Counselor in the month of September. Additionally, in review of the medical record for RRNHV #5 where the plan of care required skilled nursing visits 1 - 2 xwk there was no evidence of a nursing visit the 3rd week of September. This was validated by the DPCS and HCO leadership team.”

“Observed in Patient Home. In 1 of 4 home visits conducted, the organization did not implement its infection prevention and control activities to minimize, reduce, or eliminate the risk of infection. For RRHV #2 the RN did not follow the organization’s policy no. 9.44 Nurse Bag Technique which requires that staff establish a clean area or barrier using newspaper or paper towels to place equipment and supplies on that will be needed during the visit. The RN did not remove items for the visit and place them on the barrier but instead re-entered the nursing bag several times to retrieve needed equipment and supplies including her stethoscope and ointment & bandage for the dressing change. This was discussed with and validated by the DPCS and the leadership team. 

 Observed in Patient Home. In 1 of 4 home visits conducted, the organization did not use standard precautions to reduce the risk of infection. For RRHV #2 the RN did not follow the organization’s policy no. 9.44 Nurse Bag Technique. The RN placed soiled gloves on the kitchen chair and not in a waste receptacle as required by policy and at the end of the visit the RN handed the medical waste including soiled gloves, soiled bandage from the dressing change and the barrier on the kitchen table to the daughter and did not dispose of them in a waste receptacle as required by policy..”