Care Plus Hospice

“Based on interview and record review, the hospice failed to ensure the updated comprehensive assessments included the changes that had occurred since the initial assessment, information on the patient’s progress, and reassessment of the patient’s responses for two of three sampled patients (Patients 1 and 3). This failure had the potential to result in unmet care needs for these patients. Review of the hospice’s P&P titled Pressure Ulcer Prevention and Management revised 11/18 showed the hospice interdisciplinary team (IDT) shall assess all patients for risk of skin breakdown and pressure ulcer development upon admission and throughout the course of care. Pressure ulcer prevention and management interventions shall be individualized based on the patient’s prognosis, condition, goals of care, comfort needs, and patient/family preferences. Definitions include:Pressure Ulcer/Pressure Injury: Localized damage to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, shear, or friction. Unstageable Pressure Injury Full-thickness skin and tissue loss in which the extent of tissue damage cannot be confirmed because it is obscured by slough or eschar. Deep Tissue Pressure Injury -Persistent non-blanchable deep red, maroon, or purple discoloration. Initial AssessmentUpon admission, the hospice nurse shall: 1. Perform and document a comprehensive skin assessment within 24 hours of admission. 2. Identify: Existing pressure ulcers - Skin tears - Moisture-associated skin damage - Surgical wounds - Areas of redness or breakdown 3. Assess and document: - Location - Stage - Size (length, width, depth) - Drainage - Odor - Pain - Presence of tunneling or undermining Ongoing Assessment.The hospice nurse shall reassess skin integrity:-At each skilled nursing visit as clinically indicated-With any significant decline condition-Following transfers or hospitalization-Upon caregiver report of new skin concernsDocumentation shall include:-Changes in wound appearance-Response to treatment-Signs/symptoms of infection-Patient tolerance of interventions-Effectiveness of pain management Wound TreatmentTreatment orders shall be obtained from the physician or authorized practitioner and mayinclude:-Cleansing with appropriate wound solution-Protective barriers-Foam dressings-Hydrocolloid dressing -Alginate dressings-Odor management products-Debridement only when consistent with goals of care Documentation RequirementsClinical documentation shall include:- Wound assessment findings- Stage and measurements- Interventions provided- Patient tolerance- Pain assessment- Education provided-Communication with physician/IDT- Supplies utilized-Changes in condition 1.Review of Patient 1’s closed clinical record was initiated on 6/2/26. The clinical record showed SOC was 3/8/26. The patient was certified for hospice services during the certification periods from 3/08/2026 To 6/05/2026. Patient 1 had expired on 4/21/26. The POC/IDG Review dated 3/11, 3/25, 4/8, and 4/22/26, showed the patient’s identified care plan problem included risk for altered skin integrity as evidenced by blanchable redness on the coccyx and upper back. The interventions included assessing skin daily and monitoring for breakdown. The identified care plan problems were opened on 3/8/26. A. Review of the skin assessment showed on 3/8/26, the patient had coccyx blanchable redness. Review of the medication profile showed an order dated 3/8/26, for Calmoseptine (moisture barrier) 20.6% ointment and Vitamin A&D (skin protectant) 95% ointment to be applied twice daily and as needed with every diaper change for skin maintenance. The POC/IDG dated 3/11/26, showed the skin remained intact but flabby with blanchable redness on the coccyx indicating early pressure injury risk. Review of the skin assessment showed the following:-On 3/12/26, the patient’s skin was intact. -On 3/13/26, the patient had blanchable coccyx redness. -On 3/17/26, the patient had Stage 1 coccyx pressure injury, 4 cm (length) x 5 cm (width). -On 3/19/26, the existing redness at the coccyx was assessed. Documentation included “Noted was an open skin area at this time, which was intact, dark purple in color, and slightly raised.” Documentation also showed a Stage 1 coccyx pressure injury with a measurement of 4 cm x 5 cm. -On 3/21/26, the patient had coccyx DTI with two blisters. Documentation also showed a Stage 1 coccyx pressure injury with a measurement of 4 cm x 5 cm. There were no measurements for the coccyx DTI and two blisters. -On 3/24/26, the patient had coccyx blisters. Documentation also included a Stage 1 coccyx pressure injury with a measurement of 4 cm x 5 cm. There was no measurement documented for the coccyx DTI and the blisters. *The Skin Assessment showed inconsistency with the wound measurement as Stage 1 coccyx was measured and others were not such as the blisters identified. The POC/IDG dated 3/25/26, showed the IDG discussed the patient had DTI on coccyx with two blisters. *However, there was no documented evidence the IDG had discussed and updated the comprehensive assessment to include the changes that had occurred regarding the progression of the coccyx wound from when the patient had coccyx blanchable redness, intact skin, Stage 1 coccyx pressure injury, and coccyx DTI with two blisters. There was no documented evidence the IDG discussed consistency of the wound assessment. The Interdisciplinary Group (IDG) also did not reevaluate the preventative and treatment measures for the patient’s wounds during the IDG meetings. Review of the skin assessment showed the following:-On 3/27/26, showed the patient had coccyx DTI with a measurement of 4 cm × 5 cm. -On 3/31/26, showed the patient had both Stage 1 and DTI coccyx pressure injuries. Both were measured as 4 cm x 5 cm. -On 4/3 and 4/6/26, showed the patient had a Stage 1 coccyx pressure injury with a measurement of 4 cm x 5 cm. The POC/IDG dated 4/8/26, showed the IDG had discussed DTI present on the patient’s coccyx. *However, there was no documented evidence the IDG discussed and updated the comprehensive assessment regarding the status of Stage 1 coccyx pressure injury and discussed the consistency of the wound assessment. Review of the Nursing Updated Assessment dated 4/10/26, showed the wound care specialist visited the patient on Wednesday (4/8/26) and debrided the wound, which was a Stage 4 pressure injury. Review of the skin assessment showed the following:-On 4/10/26, the patient had Stage 4 coccyx pressure injury with a size of 5 cm x 5.5 cm x 0.6 cm. The co-existing Stage 1 pressure injury’s measurement was not documented.-On 4/13/26 and 4/15/26, no documentation of Stage 4 coccyx pressure injury measurements.-On 4/17/26, no documentation of Stage 1 coccyx pressure injury measurements.On 4/20/26, no documentation of Stage 4 coccyx pressure injury measurements. The POC/IDG dated 4/22/26, showed the patient had passed away on 4/21/26. Documentation showed the patent developed a DTI on the coccyx that progressed into a Stage 4 pressure injury. Documentation showed it was managed with antibiotics and SN visits three times a week for wound care. *However, there was no documented evidence the IDG discussed the consistency of the wound assessment. On 6/4/26 at 1500 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee stated wound assessments should be completed weekly. The Administrator Designee was informed and verified the findings. B. Review of the medication profile showed the following:-On 3/31/26, the patient was referred to the wound doctor for evaluation and treatment of pressure sores to the area below the right lateral foot. Review of the skin assessment showed the following: -On 3/27/26, a right foot DTI measuring 2 cm x 2 cm was identified. -On 3/31/26, the right foot DTI measured as 2 cm x 2 cm.-On 4/3, 4/6, 4/10, 4/13, 4/15, 4/17, 4/19, and 4/20/26, the SN visits were completed; however, no measurement of the right foot DTI documented.The Skin Assessments did not show the consistent ongoing wound assessments. The wound care company progress notes dated 4/1/and 4/8/26, showed the PA conducted a visit. Documentation showed the right foot was not included in the assessment. There was no documented evidence the hospice followed up with the wound specialist to clarify why the right foot evaluation was not completed. The POC/IDG dated 4/8 and 4/22/26, showed the IDG discussed DTI was present on the right foot. The POC/IDG dated 4/22/25, showed the patient had passed away on 4/21/25. *However, there was no documented evidence the IDG discussed the consistency of the wound assessment of the right foot DTI; and why the evaluation on the right foot was not completed by the wound care company. On 6/4/26 at 1500 hours, an interview and concurrent clinical record review was conducted with Administrator Designee. The Administrator Designee stated that skin measurement and wound assessments should be completed weekly. The Administrator Designee was informed and verified the findings. C. Review of the skin assessment showed the following:-On 3/27/26, Stage 1 left ear redness was identified.-On 3/31/26, Stage 1 left ear redness had a measurement of 3 cm x 1 cm-On 4/10/26, 4/13/26, 4/15/26, and 4/17/26, the SN visits were completed; however, no measurement for the Stage 1 left ear redness was documented. In addition, there was no documented evidence of a treatment order for the left ear redness. The POC/IDG dated 4/8 and 4/22/26, showed the IDG did not discuss and updated the comprehensive assessment regarding Stage 1 left ear redness ear. The IDG did not discuss and coordinate care with the physician regarding treatment order the Stage 1 left ear pressure injury. The IDG did not discuss the SN did not document consistent ongoing wound assessments. On 6/4/26 at 1500 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee stated the skin measurement and wound assessments should be completed weekly. The Administrator Designee was informed of the above findings and verified the findings. 2. Review of Patient 3’s clinical record was initiated on 6/2/26. The clinical record showed the SOC was 5/8/26. The patient was certified for hospice services during the certification period from 5/8/26/26 To 8/5/26. Review of the skin assessment showed the following:-On 5/8, 5/9, 5/14, and 5/19/26, bruising was noted on the right shoulder and both knees; redness was present on the coccyx and mid‑back; and an excoriation/abrasion was noted on the mid‑back. No measurements were documented. The SN notes did not show the consistent ongoing wound assessments. The POC/IDG dated 5/8/26, showed no documented evidence the IDG discussed and updated the comprehensive assessment regarding the status of the bruising on the right shoulder and both knees; redness on the coccyx and mid back; and excoriation/abrasion on the mid back. The POC/IDG dated 5/20/26, showed no documented evidence the IDG discussed and updated the comprehensive assessment regarding the status of the bruising on the right shoulder and both knees; and excoriation/abrasion on the mid back. The POC/IDG dated 5/8 and 5/20/26, showed no documented evidence the IDG discussed the consistency for wound assessments. On 6/4/26 at 1600 hours, an interview and concurrent clinical record review was conducted with Administrator Designee. The Administrator Designee was informed and verified the findings. Cross reference to L554.”

“Based on observation, interview, and record review, the hospice failed to ensure the care and services were provided in accordance with the plan of care for two of three sampled patients (Patients 1 and 3). This failure created the risk of not providing appropriate, consistent, and quality care to these patients. Findings: 1. Review of Patient 1’s closed clinical record was initiated on 6/2/26. The clinical record showed SOC was 3/8/26. The patient was certified for hospice services during the certification periods from 3/08/26 To 6/05/26. Patient 1 had expired on 4/21/26.A. Review of the medication profile showed the following:-An order dated 3/8/26, for Calmoseptine (moisture barrier) 20.6% ointment and Vitamin A&D (skin protectant) 95% ointment to be applied twice daily and as needed with every diaper change for skin maintenance. However, there were no physician’s orders for treating the coccyx skin conditions on 3/13, 3/17, 3/21, 3/24, and 3/27/26, which included blanchable redness, a Stage 1 pressure injury, and a deep‑tissue injury with blisters. For example:Review of the skin assessment showed the following:On 3/13/26, blanchable coccyx redness was noted and a skin barrier was applied.On 3/17/26, Stage 1 coccyx pressure injury was was cleansed, patted dry, and a skin barrier (Calmoseptine and Vitamin A & D ointment) was applied with every diaper change. On 3/21/26, the DTI with two blisters was noted. However, no treatment was documented.On 3/24/26, coccyx blisters were identified. Documentation showed cleansed with wound cleanser/”NSS”, patted dry, applied skin barrier cream mixed with A&D ointment, and covered with silicone bordered foam dressing.On 3/27/26, the DTI with serosanguineous drainage was treated with Calmoseptine, vitamin A & D ointment, and foam dressing. There was no physician’s order.Review of the medication profile showed the following:-An order dated 4/9/26, to cleanse sacrococcyx ulcer with “nss”/wound cleanser, pat dry, apply honey gel fiber dressing (wound dressing) to wound bed, cover with foam dressing, cover with border foam dressing, change dressing three times per weekand as needed if soiled or loss of integrity.-An order dated 4/9/26, showed crush one tablet of Flagyl (antibiotic) 500 mg and apply to wound bed of sacrococcyx wound as needed for signs/symptoms of infection during each wound care treatment.Review of the skin assessment showed the following:On 4/13, 4/15, and 4/20/26, the sacrococcyx wound was treated with crushed Flagyl, honey calcium alginate, Calmoseptine, and foam dressing, which did not follow the 4/9/26 physician’s order. Review of the Nursing Updated Assessment dated 4/17/26, showed tunnelling was present on the Stage 4 coccyx pressure injury. Documentation showed the RNCM patted the wound dry with ns soaked gauze and placed crushed Flagyl, then applied honey alginate dressing, packed with gauze and covered with sacral foam dressing .However, wound treatments performed by the SN on 4/13, 4/15, 4/17, and 4/20/26, did not follow the prescribed treatment.On 6/4/26 at 1500 hours, an interview and concurrent clinical record review was conducted with the Administrator designee. The Administrator Designee was informed of the above findings and verified the findings. On 6/4/26 at 1600 hours, the Administrator Designee confirmed the nurse communicated with the physician through the hospice’s secure clinical communication platform but did not forward the order to the hospice physician for signature. The Administrator Designee verified the hospice’s secure clinical communication platform deleted messages after 30 days and agreed the order should have been transferred and signed. The Administrator Designee verified the findings.B. Review of the medication profile showed the following:-On 3/31/26, the patient was referred to the wound care provider for the evaluation and treatment of pressure sores to the area below the right lateral foot.Review of the skin assessment showed the following:-On 3/27/26 and 3/31/26, a right‑foot DTI was noted; iodine (antiseptic) was applied, and the area was left open to air.-On 4/3/26, iodine was applied to the right‑foot DTI and left open to air;-On 4/6/26, 4/13/26, 4/15/26, 4/19/26, and 4/20/26, the SN visits were completed; however, no treatment of the right‑foot DTI were documented.-On 4/10/26 and 4/17/26, iodine was applied to the right‑foot DTI and left open to air.However, further review of the clinical record failed to show documented evidence of a treatment order for the patient’s right lateral foot DTI.On 6/4/26 at 1500 hours, an interview and concurrent clinical record review was conducted with the Administrator designee. The Administrator Designee was informed of the above findings and verified the findings. On 6/4/26 at 1600 hours, the Administrator Designee confirmed the nurse communicated with the physician through the hospice’s secure clinical communication platform but did not forward the order to the hospice physician for signature. The Administrator Designee verified the hospice’s secure clinical communication platform deleted messages after 30 days and agreed the order should have been transferred and signed. The Administrator Designee verified the findings.2. Review of Patient 2’s closed clinical record was initiated on 6/2/26. The clinical record showed SOC was 3/31/26. The patient was certified for hospice services during the certification period from 3/31/26 to 6/28/26. Patient 2 was discharged on 5/23/26. A. Coccyx woundThe medication profile showed the following:- On 3/31/26, Calmoseptine topical Ointment 20.6%, 1:1 ointment, was ordered to be applied topically twice a day and as needed with every diaper change for skin maintenance. Vitamin A&D topical Ointment 95%, 1:1 ointment, was ordered to be applied topically twice a day and as needed with every diaper change for skin maintenance.Review of the skin assessments showed the following:– On 3/31/26, redness was noted on the coccyx area. *However, there was no physician orders for the use of Calmoseptine and vitamin A&D for the coccyx redness as the above treatment order were for skin maintenance.On 6/4/26 at 1600 hours, the Administrator Designee confirmed the nurse communicated with the physician through the hospice’s secure clinical communication platform but did not forward the order to the hospice physician for signature. The Administrator Designee verified the hospice’s secure clinical communication platform deleted messages after 30 days and agreed the order should have been transferred and signed. The Administrator Designee verified the findings.3. Review of Patient 3’s clinical record was initiated on 6/2/26. The clinical record showed SOC was 5/8/26. The patient was certified for hospice services during the certification period from 5/8/26/26 To 8/5/26. A. The medication profile showed an order dated 5/21/26, for Stage 2 mid-back pressure injury as follows: to cleanse with wound cleanser, pat dry, apply a mixture of Calmoseptine and vitamin A&D and cover with a foam dressing two times a week.A joint home visit with RN 1 was conducted on 6/3/26 at 1140 hours, at the patient’s home. RN 1 was observed providing wound care to the mid‑back by cleansing the area, patting it dry, applying Calmoseptine, and covering it with a foam dressing. RN 1 did not mix the Calmoseptine with vitamin A&D as ordered. Patient 3 was observed lying on the bed with the APP mattress in place. On 6/3/26 at 1300 hours, during a concurrent medication profile review and interview, RN 1 was informed of the observed wound treatment deviation and verified the findings.On 6/3/26 at 1400 hours, RN 1 stated the treatment order had been communicated to the physician through the hospice’s secure clinical communication platform, but the message could not be retrieved because the hospice’s secure clinical communication platform automatically deletes messages after 30 days. RN 1 acknowledged the order had not been signed by the physician and should have been forwarded to the hospice physician for signature. RN 1 was informed of the observed wound treatment deviation and verified the findings.On 6/4/26 at 1600 hours, the Administrator Designee confirmed the nurse communicated with the physician through the hospice’s secure clinical communication platform but did not forward the order to the hospice physician for signature. The Administrator Designee verified the hospice’s secure clinical communication platform deleted messages after 30 days and agreed the order should have been transferred and signed. The Administrator Designee verified the findings.b. The medication profile showed the following:-On 5/8/26, Calmoseptine 20.6% ointment and vitamin A&D 95% ointment to be applied twice daily and as needed with every diaper change for skin maintenance.Review of the skin assessment showed the following:-On 5/9/26, coccyx redness was present and was treated with barrier cream after each diaper change.However, there was no physician’s order for the treatment of the coccyx redness on 5/9/26, as the treatment order for Calmoseptine and vitamin A&D dated 5/8/26, was for skin maintenance.On 6/3/26 at 1400 hours, RN 1 stated the treatment order had been communicated to the physician through the hospice’s secure clinical communication platform, but the message could not be retrieved because the hospice’s secure clinical communication platform automatically deleted messages after 30 days. RN 1 acknowledged the order had not been signed by the physician and should have been forwarded to the Hospice physician for signature. On 6/4/26 at 1600 hours, the Administrator Designee was informed and verified the findings.Cross reference to L554.”

“Based on interview and record review, the hospice failed to ensure the individualized care plans were developed for two of three sampled patients (Patients 1 and 2). This failure had the potential to cause inconsistent delivery of care which can result in the decline or lack of improvement of the patients’ health conditions. Findings: Review of the hospice’s P&P titled The Plan of Care revised 11/2018 showed the following:12.The written plan of care will contain, but will not be limited to, the following:A.DiagnosisB.Identification of patient and family/caregiver needs, including physical, psychosocial, cognitive, cultural, spiritual, nutritional, functional, educational, and counseling.C. Reduction in risk factorsD. Functional limitationsE. Mental statusF. Safety measures to protect against abuse, injury, infection, or communicable disease, as appropriateG. Nutritional requirementsH. PrognosisI. DME and medical supplies necessary to meet patient needsJ. Frequency and type of servicesK. Placement at the appropriate level of care and referrals as needed for counseling, additional disciplines, volunteers, and adjunctive servicesL. Individualized interventions to assist with end-of-life careM.Patient and family/caregiver educational needs and assessment of their ability to learn and understand teachingN. Statement of treatment goalsO. Interdisciplinary group assessment of needsP. Pain and symptom management interventionsQ. Drugs and treatments (including allergies)R.Physician-directed instruction to patient and family/caregiverS.Physician (or other authorized licensed independent practitioner) ordersT.Measurable outcomes anticipated from implementing and coordinating the plan of careU.Patient or representative’s level of understanding, involvement and agreement with the plan of care and goalsV.Anticipated discharge and bereavement care needs of the family 1.Review of Patient 1’s closed clinical record was initiated on 6/2/26. The clinical record showed SOC was 3/8/26. The patient was certified for hospice services during the certification periods from 3/08/2026 To 6/05/2026. Patient 1 had expired on 4/21/26. A. The medication profile showed the following:On 3/8/26, the patient was prescribed Tylenol (analgesic) 325 mg two tablets every four hours as needed (max 3 g/day), Morphine (opioid analgesic) 15 mg tablets ½ tablet every four hours as needed, Morphine 20 mg/ml solution 0.25 ml every four hours as needed, and Eliquis (blood thinner) 5 mg once daily.On 3/11/26, the patient was prescribed Tylenol Extra Strength 500 mg two tablets three times daily for moderate to severe pain.On 3/27/26, Norco 5/325 mg, 1–2 tablets every four hours as needed for moderate pain was ordered.On 4/13/26, Morphine 20 mg/mL solution, 0.25 ml (5 mg) every four hours as needed for moderate pain was ordered.On 4/17/26, Morphine 20 mg/mL solution, 0.25 ml (5 mg), was ordered to be given before diaper changes, bed baths, or wound‑care treatments.However, there was no documentation the IDG developed an individualized POC addressing Patient 1’s pain management or risk for bleeding related to Eliquis. On 6/4/26 at 1500 hours, an interview and concurrent clinical record review were conducted with the Administrator Designee. The Administrator Designee was informed of the above findings and verified the findings. 2. Review of Patient 2’s closed clinical record was initiated on 6/2/26. The clinical record showed SOC was 3/31/26. The patient was certified for hospice services during the certification periods from 3/31/26 To 6/28/26. Patient 2 had expired on 5/23/26. Review of the skin assessments showed the following:-On 3/31/26, redness was noted on the coccyx area. –On 4/2/26 and 4/6/26, several small, different‑sized areas of blanchable skin redness were noted between the patient’s buttocks. The POC/IDG reviews dated 4/1/26 and 4/8/26, showed there was no documentation the IDG had developed an individualized POC to address Patient 1’s integumentary. On 6/4/26 at 1600 hours, an interview and concurrent clinical record review were conducted with the Administrator Designee. The Administrator Designee was informed of the above findings and verified the findings.Cross reference to L554.”

“Based on interview and record review, the hospice failed to ensure the IDG had reviewed/revised the patient’s POCs no less frequently than every 15 calendar days for two of three sampled patients (Patient 1, and 3). This failure had the potential for not providing appropriate, consistent, and quality care to these patients. Review of the hospice’s P&P titled Interdisciplinary Group Meeting Revised 11/18 showed the interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patient’s plan of care will be updated utilizing the results from the ongoing comprehensive assessment, no less frequently than every 15 days or more frequently if the patient’s condition requires. Review of the hospice agency’s P&P titled Pressure Ulcer Prevention and Management Policy & Procedure Revised 11/18 showed the hospice interdisciplinary team (IDT) shall assess all patients for risk of skin breakdown andpressure ulcer development upon admission and throughout the course of care. Pressure ulcer prevention and management interventions shall be individualized based on the patient’s prognosis, condition, goals of care, comfort needs, and patient/family preferences. Definitions included:Pressure Ulcer/Pressure Injury: Localized damage to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, shear, or friction. Unstageable Pressure Injury: Full-thickness skin and tissue loss in which the extent of tissue damage cannot be confirmed because it is obscured by slough or eschar. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon, or purple discoloration.1.Review of Patient 1’s closed clinical record was initiated on 6/2/26. The clinical record showed SOC was 3/8/26. The patient was certified for hospice services during the certification periods from 3/08/2026 To 6/05/2026. Patient 1 had expired on 4/21/26. Review of the skin assessment showed the following:-On 3/8/26, the patient had coccyx blanchable redness.-On 3/12/26, the patient’s skin was intact.-On 3/13/26, the patient had blanchable coccyx redness.-On 3/17/26, the patient had Stage 1 coccyx pressure injury. -On 3/19/26, the existing redness at the coccyx was assessed. Documentation included “Noted was an open skin area at this time, which was intact, dark purple in color, and slightly raised.” Documentation included a Stage 1 coccyx pressure injury with a measurement of 4 cm x 5 cm.-On 3/21/26, the patient had coccyx DTI with two blisters. -On 4/10/26, showed the patient had Stage 4 coccyx pressure injury. Review of the medication profile showed the following:-An order dated 3/31/26, to refer the patient to the wound care provider to evaluate and treat as necessary for pressure sores to the coccyx area and below right lateral foot. -An order dated 4/9/26, to cleanse sacrococcyx ulcer with “nss”/wound cleanser, pat dry, apply honey gel fiber dressing (wound dressing) to wound bed, cover with foam dressing, cover with border foam dressing, change dressing three times per week and as needed if soiled or loss of integrity. -An order dated 4/9/26, showed crush one tablet of Flagyl (antibiotic) 500 mg and apply to wound bed of sacrococcyx wound as needed for signs/symptoms of infection during each wound care treatment The POC/IDG Review dated 3/11/26, 3/25/26, 4/8/26, and 4/22/26, showed the patient’s identified care plan problem included risk for altered skin integrity as evidenced by blanchable redness on the coccyx and upper back. The interventions included repositioning at least every 2 hours, using pressure‑relieving devices and skin barrier creams, assessing skin daily and monitoring for breakdown, and educating caregivers on pressure injury prevention. The identified problems were opened on 3/8/26. *However, there was no documented evidence the identified care plan problems were updated to reflect the patient’s ongoing wound changes or to provide appropriate care. The individualized POC was not updated to address the pressure ulcers when they were identified. On 6/4/26 at 1500 hours, an interview and concurrent clinical record review was conducted with the Administrator Designee. The Administrator Designee stated skin measurement and wound assessments should be completed weekly. The Administrator Designee was informed and verified the findings. B. Review of the skin assessment showed the following: -On 3/27/26, a right foot DTI was identified. Review of the medication profile showed the following:-On 3/31/26, the patient was referred to Wound Docs for evaluation and treatment of pressure sores to the area below the right lateral foot. The POC/IDG Review dated 3/11/26, 3/25/26, 4/8/26, and 4/22/26, showed the patient’s identified care plan problem included risk for altered skin integrity as evidenced by blanchable redness on the coccyx and upper back. The interventions included repositioning at least every two hours, using pressure‑relieving devices and skin barrier creams, assessing skin daily and monitoring for breakdown, and educating caregivers on pressure injury prevention. The identified care plan problems were opened on 3/8/26. *However, there was no documented evidence the identified care plan problems were updated to reflect the patient’s ongoing wound changes or to provide appropriate care. On 6/4/26 at 1500 hours, an interview and concurrent clinical record review was conducted with the Administrator designee. The Administrator Designee was informed and verified the findings. The individualized POC was not updated to address the pressure ulcers when they were identified. Cross reference to L554. C. Review of the skin assessment showed the following: -On 3/27/26 and 3/31/26, redness behind the left ear was documented as Stage 1 pressure injury. The POC/IDG Review dated 3/11/26, 3/25/26, 4/8/26, and 4/22/26, showed the patient’s identified care plan problem included risk for altered skin integrity as evidenced by blanchable redness on the coccyx and upper back. The interventions included repositioning at least every two hours, using pressure‑relieving devices and skin barrier creams, assessing skin daily and monitoring for breakdown, and educating caregivers on pressure injury prevention. The identified care plan problems were opened on 3/8/26. However, there was no documented evidence the identified care plan problems were updated to reflect the patient’s ongoing wound changes or to provide appropriate care. The IDG did not coordinate care with the physician regarding the left ear redness. On 6/4/26 at 1500 hours, an interview and concurrent clinical record review was conducted with Administrator Designee. The Administrator Designee was informed and verified the findings. The individualized POC was not updated to address the pressure ulcers when they were identified. D. Review of the Visit Notes by the LVN dated 4/20/26 showed that the caregiver reported that upon her arrival, the patient was pocketing food and had food all over her chest. The patient was at risk for aspiration due to pocketing food and decreased ability to swallow.The POC/IDG Reviews dated 3/11/26, 3/25/26, 4/8/26, and 4/22/26, showed the patient’s identified care plan problem included significant weight loss (13.97 lbs., 10.4%), fair appetite, prolonged eating time, dysphagia, and reliance on liquid supplements. The interventions included a mechanical diet with nutritional supplements (Ensure), allowing extended mealtimes, assisting as needed, monitoring weekly weight and intake, encouraging small frequent meals and hydration, and providing oral care before and after meals.However, there was no documented evidence the identified care plan problems were updated to provide appropriate care for the patient.On 6/4/26 at 1045 hours, an interview and concurrent clinical record review were conducted with LVN 2. LVN 2 acknowledged it should have been communicated and discussed in the IDT meeting. LVN 2 verified the findings.On 6/4/26 at 1500 hours, an interview and concurrent clinical record review were conducted with the Administrator designee. The Administrator designee was informed of the above findings and verified the findings 2. Review of Patient 3’s clinical record was initiated on 6/2/26. The clinical record showed the SOC was 5/8/26. The patient was certified for hospice services during the certification periods from 5/8/26/26 to 8/5/26. The medication profile showed an order on 5/8/26, Calmoseptine 20.6% ointment and vitamin A&D 95% ointment to be applied twice daily and as needed with every diaper change for skin maintenance. Review of the skin assessment showed the following:-On 5/8, 5/9, 5/14, and 5/19/26, bruising was noted on the right shoulder and both knees; redness was present on the coccyx and mid‑back; and an excoriation/abrasion was noted on the mid‑back. The POC/IDG reviews dated 5/8, 5/13, and 5/20/26, showed the patient’s identified care plan problem included at risk for skin breakdown and impaired skin integrity related to immobility, edema, incontinence, and poor nutritional status. The interventions included assessing alteration in skin integrity every visit, assess/monitor effectiveness of wound treatments, and the use of a special APP mattress, low air loss mattress, egg crate, or gel mattress. The identified care plan problems were opened on 5/8/26. A joint home visit with RN 1 was conducted on 6/3/26 at 1140 hours, at the patient’s home. Patient 3 was observed lying on the bed with the APP mattress in place. *However, there was no documented evidence that the identified care plan problems were updated to reflect the patient’s ongoing wound changes and the specific intervention provided to the patient such as the mattress type. On 6/4/26 at 1600 hours, the Administrator Designee was informed and verified the findings. The individualized POC was not updated to address the pressure ulcers when they were identified. Cross reference to L554.”

“Based on interview and record review, the hospice failed to ensure the IDT maintained the responsibility for directing and supervising the care and services provided for three of three sampled patients (Patients 1, 2, and 3). This failure created the risk of not addressing the care needs for these patients. Review of the hospice’s P&P titled Interdisciplinary Group Coordination of Care revised 11/18 showed the interdisciplinary group will maintain responsibility for the provision and coordination of care, regardless of the setting where care is provided to its patients. It will be the responsibility of the RN Case Manager to facilitate communication about changes in the patient’s status among interdisciplinary group members and the patient’s attending physician. Personnel will communicate changes in a timely manner via telephone, one-to-one meetings, interdisciplinary group meetings, and home visits. Documentation of all communications will be included in the clinical record on a communication note, interdisciplinary group meeting form, and/or clinical note. Documentation will include the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication. Written evidence of care coordination will be found in the plan of care and/or interdisciplinary group meeting forms in the patient’s clinical record and will involve the hospice patient’s attending physician. Written evidence of care coordination will be found in the plan of care and/or interdisciplinary group meeting forms in the patient’s clinical record and will involve the hospice patient’s attending physician. Review of the hospice’s P&P titled Interdisciplinary Group Meeting Revised 11/18 showed the interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Exchange of information between hospice staff and contracted providers will be documented in the clinical record. 1. Review of the clinical records for Patients 1, 2, and 3 showed the following: - Patient 1’s closed clinical record was initiated on 6/2/26. The clinical record showed SOC was 3/8/26. The patient was certified for hospice services during the certification periods from 3/08/2026 To 6/05/2026. Patient 1 was discharged on 4/21/26. - Patient 2’s closed clinical record was initiated on 6/2/26. The clinical record showed SOC was 3/31/26. The patient was certified for hospice services during the certification period from 3/31/26 to 6/28/26. Patient 2 was discharged on 5/23/26. - Patient 3’s clinical record was initiated on 6/2/26. The clinical record showed SOC was 5/8/26. The patient was certified for hospice services during the certification period from 5/8/26/26 To 8/5/26. Further review of the clinical record showed the following: - The updated comprehensive assessments did not include the changes that had occurred since the initial assessment, information on the patient’s progress, and reassessment of the patient’s responses for Patients 1 and 3. Cross reference to L533. - The care and services were not provided in accordance with the plan of care for Patients 1 and 3. Cross reference to L543. - The individualized care plans were not developed for Patients 1 and 2. Cross reference to L545. - The IDG did not review/revise the patient’s POCs no less frequently than every 15 calendar days for Patients 1 and 3. Cross reference to L552. - The family and/or other caregiver(s) were not provided with the instruction on the safe use of the air‑loss mattress for Patients 1 and 2. Cross reference to L702. The IDG failed to maintain responsibility for directing and supervising the care and services provided the patients.2.a. Review of Patient 1’s clinical record showed the Medication profile included the following medications:- On 3/8/26, Tylenol 325 mg two tablets every four hours as needed (max 3 g/day), Morphine 15 mg tablets (½ tablet every four hours as needed, Morphine 20 mg/ml solution 0.25 ml every four hours as needed, and Eliquis 5 mg once daily.- On 4/13/26, Morphine Sulfate 20 mg/mL concentrated solution 0.25 ml (5 mg) orally every four hours as needed for moderate pain (pain level of 4–6, on a 0-10 pain scale with 0=no pain and 10=worst pain) was ordered.- On 4/17/26, Morphine Sulfate 20 mg/mL concentrated solution 0.25 ml (5 mg) orally was ordered to be administered before every diaper change, bed bath, or wound care treatment.Review of the Communication Log dated 3/8/26 at 2250 hours, showed the pharmacy contacted the staff regarding the morphine order due to the patient’s codeine allergy. The RN was notified, and a message was sent to the physician regarding possibly changing the medication to Dilaudid (opioid analgesic). The POC/IDG Reviews dated 3/11/26, 3/25/26, 4/8/26, and 4/22/26, showed the patient’s identified care plan problem included the patient was bedbound, had weakness, was at risk for contractures, and experienced pain during repositioning. The patient also had a history of joint replacements and kyphoplasty (vertebral compression fracture). The interventions included monitoring and managing pain during repositioning. However, there was no documentation of coordination with the physician regarding the patient’s morphine allergy and morphine order. There was no documentation the family was updated regarding changes to the morphine medication profile.- on 6/4/26 at 1500 hours, an interview and concurrent clinical record review was conducted with the Administrator designee. The Administrator designee was informed of the above findings and verified the findings. b. Review of the Communication Log dated 4/21/26 showed at 0853 hours, a call was received from the family stating that the patient was unresponsive but breathing and comfortable. End‑of‑life information was explained to the family, and the family stated they would wait for the nurse to arrive. The family was informed that LVN 2 would see the patient around noon, and they were agreeable. The administrator designee verified the findings.Review of the Visit Notes – Death Visit dated 4/21/26, showed the hospice assisted the family with mortuary arrangements, provided postmortem care, and offered support to the bereaved family.On 6/8/26 at 0800 hours, an interview and concurrent clinical record review were conducted with LVN 1. LVN 1 stated the family called and reported the patient was unresponsive but breathing and comfortable. LVN 1 stated she would look for the nurse. Approximately 10 minutes later, LVN 1 called the family back to inform them that a nearby nurse could be sent; however, the family refused and preferred to wait for LVN 1 to arrive at noon. LVN 1 was asked if she had documented the communication with the family. LVN 1 stated the communication was recorded in the communication system, and the communication would disappear from the system after 30 days.On 6/8/26 at 1520 hours, an interview was conducted with RN 2. RN 2 stated she was called for a death visit. RN 2 stated RN 2 offered the family to provide postmortem care, but the family refused, stating they had already changed the patient.On 6/8/26 at 1600 hours, an interview and concurrent clinical record review were conducted with the Administrator designee. The Administrator designee was informed of the above findings. The Administrator designee stated the documentation should have been recorded in the electronic clinical records. The Administrator designee acknowledged there was no documentation showing that LVN 1 communicated with the family regarding the visiting nurse, or that RN 2 documented the family’s refusal of postmortem care. The administrator designee verified the findings.The IDG failed to maintain responsibility for directing and supervising the care and services provided the patients.”

“Based on interview and record review, the hospice failed to ensure that the family and/or other caregiver(s) received instruction on the safe use of the air‑loss mattress for two of the three sampled patients (Patients 1 and 2). This failure had the potential for poor health outcomes for this patient. Findings: 1. Review of Patient 1’s closed clinical record was initiated on 6/2/26. The clinical record showed the SOC date was 3/8/26. The patient was certified for hospice services during the certification period from 3/08/2026 to 6/05/2026. Patient 1 was discharged on 4/21/26.The medication profile showed the following: -On 3/8/26, a hospital bed with full rails was ordered.Review of the Med Plus DME form dated 3/8/26, showed Patient 1 received a full electric bed and a low air‑loss mattress.However, there was no documented physician’s order for the provision of a low air‑loss mattress.The POC/IDG reviews dated 3/11/26, 3/25/26, 4/8/26, and 4/22/26, showed the patient’s identified care‑plan problem included at risk for altered skin integrity, as evidenced by blanchable redness on the coccyx and upper back. The interventions included repositioning at least every 2 hours, using pressure‑relieving devices and skin‑barrier creams, assessing skin daily and monitoring for breakdown, and educating caregivers on pressure‑injury prevention. These identified care plan problems were opened on 3/8/26.However, there was no documented evidence education was provided to the caregiver or family regarding the use of the air‑loss mattress with appropriate settings from 3/8/26 to 3/31/26.On 6/4/26 at 1500 hours, an interview and concurrent clinical record review were conducted with the Administrator designee. The Administrator designee was informed of the above findings and verified the findings.2. Review of Patient 2’s closed clinical record was initiated on 6/2/26. The clinical record showed the SOC date was 3/31/26. The patient was certified for hospice services during the certification period from 3/31/26 to 6/28/26. Patient 2 had expired on 5/23/26.The medication profile showed the following: -On 3/31/26, a low air‑loss mattress was ordered for wound management and skin integrity.Review of the MedPlus DME form dated 3/31/26, showed Patient 2 received a low air‑loss mattress.Review of the SN notes dated 3/31, 4/2, 4/6, and 4/10/26 showed nNo documented evidence education was provided to the caregiver or family regarding the use of the air-loss systemThe POC/IDG reviews dated 4/1/26 and 4/8/26, showed no documented education provided to the caregiver or family regarding the use of the air‑loss mattress with appropriate settings. On 6/4/26 at 1600 hours, an interview and concurrent clinical record review were conducted with the Administrator designee. The Administrator designee was informed of the above findings and verified the findings.Cross reference to L554.”

“Observed in Record Review. In 4 of 14 patient records reviewed, for active patients, it was noted by the nurse surveyor that orders were not clear or complete. For RRHV#3 the oxygen orders were for Oxygen 2 to 5 liters per minute binasal cannula as needed. Orders did not include parameters for titration or where the liter flow was to start. For RRNHV#4, the oxygen orders were for Oxygen 2 to 5 liters per minute binasal cannula as needed, however, the patient was actually using 2 liters oxygen continuously. For RRNHV#1, the patient orders were for oxygen 4 liters BNC continuously, however documentation in the electronic medical record indicated that the patient was using 2 liters BNC continuously. For RRNHV#8, the oxygen orders were for Oxygen 2 to 4 liters per minute binasal cannula as needed. Orders did not include parameters for titration or where the liter flow was to start. Findings were discussed with the Director of Clinical Services and the Administrator.”

“Observed in Record Review. In 14 of 14 patient records reviewed, for active patients, it was noted by the nurse surveyor that PRN frequencies for the skilled nurse, medical social worker, and spiritual counselor did not have a reason for when to make the as needed PRN visits (they were not qualified). For RRHV#1, RRHV#2, RRHV#3, RRHV#4, RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4, RNHV#5, RRNHV#6, RRNHV#7, RRNHV#8, RRNHV#9, and RRNHV#10 all PRN visit frequencies for all disciplines were quantified for a number of how many could be made, but not for the reason in which they would be made. Finding was verified by the CEO/Administrator and the DPCS.”

“Observed in Patient Home. In 2 of 4 home visits conducted, it was observed that the medication profile was inaccurate. During RRHV#3 it was noted that the medication profile did not accurately reflect the medications that the patient was taking. The patient’s Caregiver was no longer giving DuoNeb’s which were ordered twice a day. During RRHV#4, it was noted that the caregiver was not giving the patient Potassium Chloride or Levothyroxine as ordered. Additionally, she was giving the patient Iron tablets twice a day and a Baby ASA daily which was not on the plan of care. Findings were verified by the Director of Patient Care Services who was present on the home visits.”