Physician’s Choice Hospice LLC

“Based on interview and record review, the hospice failed to ensure the initial comprehensive nursing assessments were complete and included baseline data such as the height and/or weight for five of 14 sampled patients (1, 2, 4, 6, and 7). This failure had the potential to prevent the interdisciplinary group (IDG) from establishing an accurate baseline nutritional and functional status, which could lead to inaccurate care planning for the patients.Findings: 3. A Review of Patient 2’s facesheet indicated Patient 2’s start of care was on 3/12/26. A review of Patient 2’s “CTI” dated 7/3/26. indicated the patient was certified for hospice services during the certification period from 3/12/26 to 5/10/26, 5/11/26 to 7/9/26 and 7/10/26 to 9/7/26. A review of Patient 2’s “Comprehensive Nursing Assessment” dated 3/12/26, indicated under “Vitals and Measurements”, the Height and Weight measurements were blank. During a concurrent interview and clinical record review on 8/4/26 at 09:10 AM with the Administrator, Patient 2’s “Comprehensive Nursing Assessment” dated 8/2/25 was reviewed. The Administrator verified the initial comprehensive assessment did not include the patient’s height or weight. The Administrator stated assessing the patient’s height and weight is important with establishing the patient’s clinical baseline and help monitor any changes with the patient’s health. 4. A Review of Patient 6’s facesheet indicated Patient 6’s start of care was on 11/11/25. A review of Patient 6’s “CTI” dated 11/11/25. indicated the patient was certified for hospice services during the certification period from 11/11/25 to 2/8/26. A review of Patient 6’s “Comprehensive Nursing Assessment (HOPE Assessment)” dated 11/11/25, indicated under “Vitals and Measurements”, the Height and Weight measurements were blank. During a concurrent interview and clinical record review on 8/4/26 at 09:10 AM with the Administrator, Patient 6’s “Comprehensive Nursing Assessment” dated 8/2/25 was reviewed. The Administrator verified the initial comprehensive assessment did not include the patient’s height or weight. The Administrator stated assessing the patient’s height and weight is important with establishing the patient’s clinical baseline and help monitor any changes with the patient’s health. 5. A Review of Patient 7’s facesheet indicated Patient 7’s start of care was on 8/8/25. A review of Patient 7’s “CTI” dated 8/2/25. indicated the patient was certified for hospice services during the certification period from 8/2/25 to 10/30/25. A review of Patient 7’s “Comprehensive Nursing Assessment” dated 8/4/25, indicated under “Vitals and Measurements”, the Height and Weight measurements were blank. During a concurrent interview and clinical record review on 8/4/26 at 09:10 AM with the Administrator, Patient 7’s “Comprehensive Nursing Assessment” dated 8/2/25 was reviewed. The Administrator verified the initial comprehensive assessment did not include the patient’s height or weight. The Administrator stated assessing the patient’s height and weight is important with establishing the patient’s clinical baseline and help monitor any changes with the patient’s health. 1. A review of Patient 4’s face sheet (a page in the medical record that contains a summary of basic information about the patient) indicated the patient’s start of care (SOC) was on 3/14/26.A review of Patient 4’s “Comprehensive Nursing Assessment (HOPE Admission)” dated 3/14/26 indicated an initial comprehensive assessment was completed. However, under the “Vitals and Measurements” section, Patient 4’s height and weight were left blank. Further review of the initial comprehensive nursing assessment indicated no documented evidence that Patient 4’s baseline height and weight were obtained.During a concurrent interview and clinical record review with the Director of Patient Care Services (DPCS) on 8/4/26 at 9:14 AM, Patient 4’s “Comprehensive Nursing Assessment (HOPE Admission)” dated 3/14/26 was reviewed. The DPCS verified Patient 4’s height and weight were not documented. The DPCS stated it was often difficult to obtain the patients’ height and weight due to their condition.2. A review of Patient 1’s face sheet indicated the patient’s SOC was on 7/10/26.A review of Patient 1’s “Comprehensive Nursing Assessment (HOPE Admission)” dated 7/10/26 indicated an initial comprehensive assessment was completed. However, under the “Vitals and Measurements” section, Patient 1’s weight was left blank. Further review of the initial comprehensive nursing assessment indicated no documented evidence that Patient 1’s baseline weight was obtained.During a concurrent interview and clinical record review with the DPCS on 8/4/26 at 9:08 AM, Patient 1’s “Comprehensive Nursing Assessment (HOPE Admission)” dated 7/10/26 was reviewed. The DPCS verified Patient 1’s weight was not documented.3. A review of Patient 2’s face sheet indicated Patient 2’s SOC was on 3/12/26. A review of Patient 2’s “Comprehensive Nursing Assessment (HOPE Admission)” dated 3/12/26 indicated an initial comprehensive assessment was completed. However, under the “Vitals and Measurements” section, Patient 2’s height and weight were left blank. Further review of the initial comprehensive nursing assessment indicated no documented evidence that Patient 2’s baseline height and weight were obtained.During a concurrent interview and clinical record review on 8/4/26 at 9:10 AM with the Administrator, Patient 2’s “Comprehensive Nursing Assessment (HOPE Admission)” dated 8/2/25 was reviewed. The Administrator stated assessing the patient’s height and weight is important with establishing the patient’s clinical baseline and to help monitor any changes with the patient’s health. The Administrator confirmed assessing the patient’s height and weight were part of the initial assessment. The Administrator verified Patient 2’s initial comprehensive assessment did not include the patient’s height and weight. 4. A review of Patient 6’s face sheet indicated Patient 6’s SOC was on 11/11/25. A review of Patient 6’s “Comprehensive Nursing Assessment (HOPE Assessment)” dated 11/11/25 indicated an initial comprehensive assessment was completed. However, under the “Vitals and Measurements” section, Patient 6’s height and weight were left blank. Further review of the initial comprehensive nursing assessment indicated no documented evidence that Patient 6’s baseline height and weight were obtained.During a concurrent interview and clinical record review on 8/4/26 at 9:16 AM with the Administrator, Patient 6’s “Comprehensive Nursing Assessment (HOPE Admission)” dated 11/11/25 was reviewed. The Administrator verified the initial comprehensive assessment did not include the patient’s height and weight. The Administrator stated when the patient is bedbound, the staff should document that they are unable to weight the patient. The Administrator stated assessing the patient’s height and weight is important with establishing the patient’s clinical baseline and to help monitor any changes with the patient’s health. 5. A review of Patient 7’s face sheet indicated Patient 7’s SOC was on 8/4/25. A review of Patient 7’s “Comprehensive Nursing Assessment” dated 8/4/25 indicated an initial comprehensive assessment was completed. However, under the “Vitals and Measurements” section, Patient 7’s height and weight were left blank. Further review of the initial comprehensive nursing assessment indicated no documented evidence that Patient 7’s baseline height and weight were obtained.During a concurrent interview and clinical record review on 8/4/26 at 09:30 AM with the Administrator, Patient 7’s “Comprehensive Nursing Assessment” dated 8/4/25 was reviewed. The Administrator verified the initial comprehensive assessment did not include the patient’s height and weight. The Administrator stated assessing the patient’s height and weight is important with establishing the patient’s clinical baseline and help monitor any changes with the patient’s health. A review of the hospice’s policy and procedure titled “COMPREHENSIVE ASSESSMENT” revised on November 2013 indicated “…During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient’s clinical record…””

“Based on observation, interview, and record review, the hospice failed to ensure the medication profile was updated to reflect the current medications for one of three sampled patients (Patient 1).This failure created the risk for Patient 1 not receiving the appropriate care and services necessary to alleviate his health condition. Findings: A review of Patient 1’s face sheet (a page in the medical record that contains a summary of basic information about the patient) indicated the patient’s start of care (SOC) was on 7/10/26.A review of Patient 1’s “CTI [Certification of Terminal Illness - a document indicating that a patient has a prognosis of six months or less to live if the illness runs its normal course]” dated 7/10/26 indicated the patient was certified for hospice services during the certification period from 7/10/26 to 9/7/26.A review of Patient 1’s “CURRENT TREATMENT/MEDICATION/DME [Durable Medical Equipment] List” indicated an order for ibuprofen 400 milligrams (mg – a metric unit of measurement, used for medication dosage and/or amount) one tablet orally (by mouth) every six hours as needed for moderate to severe pain.During a joint home visit at Patient 1’s home on 7/28/26 at 3:45 PM with Hospice Aide (HA) 1, Patient 1’s current medications and “CURRENT TREATMENT/MEDICATION/DME” were reviewed in the presence of the patient’s caregiver (PCG). Upon review, it was noted that Patient 1 was currently taking a liquid form of ibuprofen instead of a tablet. The bottle indicated to administer ibuprofen 100 mg per 5 milliliters (ml - metric unit of measurement for volume of a liquid) for a total of 400 mg orally as needed every six hours for moderate pain. When asked about the medication, the PCG stated Patient 1 had difficulty swallowing the ibuprofen tablets, so she asked to have it switched to liquid. The PCG stated the hospice was aware; however, the PCG was unable to recall when the change occurred but confirmed that it was not a recent change.During an interview on 8/4/26 at 9:08 AM with the Director of Patient Care Services (DPCS), the DPCS was informed and acknowledged the findings. The DPCS stated she was unaware of when the ibuprofen was changed from tablet to liquid form.A review of the hospice’s policy and procedure titled “Medication Profile” revised on November 2013 indicated “…Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications…””

“Based on interview and record review, the hospice failed to ensure the primary caregiver (PCG) received education and training in performing blood sugar checks for one of 14 sampled patients (Patient 5).This failure had the potential to prevent safe monitoring of Patient 5’s blood sugar levels, which could lead to delayed interventions and avoidable health complications. Findings:A review of Patient 5’s face sheet (a page in the medical record that contains a summary of basic information about the patient) indicated the patient’s start of care (SOC) was on 12/2/25.A review of Patient 5’s “CTI [Certification of Terminal Illness - a document indicating that a patient has a prognosis of six months or less to live if the illness runs its normal course]” dated 2/17/26 indicated the patient was recertified for hospice services during the certification period from 3/5/26 to 5/30/26.A review of Patient 5’s “POC/IDG Review [Plan of Care/Interdisciplinary Group – a document outlining the plan of care and physician orders as determined through collaborative discussions by the team responsible for the patient’s care]” dated 3/9/26 indicated a POC for the patient’s endocrine (the body’s hormone system) issues. The interventions included the following: “SN [Skilled Nurse] will educate patient/pcg on how to properly assess blood sugar using a glucometer [a small, portable machine used to check the amount of sugar in the blood]…Pcg and patient are competent in checking the patient’s blood sugar daily. SN/pcg/ family will perform blood sugar checks if patient shows signs or symptoms of hypoglycemia [low blood sugar]/hyperglycemia [high blood sugar]…SN or caregiver will perform blood sugar checks two times per day (morning before breakfast and evening before dinner) and as needed for signs/ symptoms of hypoglycemia/ hyperglycemia…”Further review of Patient 5’s clinical records indicated no documented evidence showing the staff educated the PCG on how to properly assess blood sugar and if competency was checked to ensure the PCG was able to follow the POC properly.During a concurrent interview and clinical record review with the Director of Patient Care Services (DPCS) on 8/4/26 at 9:20 AM, Patient 5’s clinical records including the initial “Comprehensive Nursing Assessment (HOPE Admission)” dated 12/2/25 were reviewed. The DPCS verified there was no documented evidence indicating an education related to the proper assessment of Patient 5’s blood sugar was provided to the PCG and if a competency check was conducted to ensure the PCG was able to perform the care appropriately. The DPCS stated teaching was normally provided to the PCG upon admission and a return demonstration was requested to ensure the PCG was competent in performing certain tasks. The DPCS stated Patient 5’s PCG was educated on how to properly perform blood sugar checks but confirmed that it was not documented.”

“Based on interview and record review, the hospice failed to develop an individualized Plan of Care (POC - the plans showing specific interventions to provide effective and person-centered care to meet the patient’s needs) for one of 14 sampled patients (Patient 4) when the patient’s right buttock pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) reopened.This failure created the risk for the hospice’s interdisciplinary group (IDG) to make care planning decisions without the most current and accurate patient information.Findings: A review of Patient 4’s face sheet (a page in the medical record that contains a summary of basic information about the patient) indicated the patient’s start of care (SOC) was on 3/14/26.A review of Patient 4’s “Nursing Re-Cert Assessment” dated 5/5/26 indicated the patient had a right buttock Stage 2 (partial-thickness loss of skin, presenting as a shallow open sore or wound) pressure injury noted on 3/14/26 which was treated and eventually resolved on 3/19/26. The notes further indicated that the pressure injury reopened on 5/5/26, and orders were obtained from the physician to treat it. A review of Patient 4’s “POC/IDG Review [Plan of Care/Interdisciplinary Group – a document outlining the plan of care and physician orders as determined through collaborative discussions by the team responsible for the patient’s care]” dated 5/18/26 indicated a POC was developed for Patient 4’s integumentary/skin problems. The POC identified the goals and interventions for the following issues:-Impaired skin integrity as evidenced by penile glans moisture associated skin damage-Impaired skin integrity as evidenced by reopened right forearm skin tear-Impaired skin integrity as evidenced by right lower leg skin tear-Pruritus (itchy skin)Further review of the “POC/IDG Review” dated 5/18/26 indicated no documented evidence a POC was developed for Patient 4’s right buttock Stage 2 pressure injury. There was also no documented evidence indicating the goals and interventions for this issue. During a concurrent interview and clinical record review with the Director of Patient Care Services (DPCS) on 8/4/26 at 9:14 AM, Patient 4’s “Nursing Re-Cert Assessment” dated 5/5/26 and “POC/IDG Review” dated 5/18/26 were reviewed. The DPCS verified an order was obtained to treat the pressure injury, but it was not documented in the POC. The DPCS verified there was no individualized POC developed for Patient 4’s right buttock Stage 2 pressure injury.A review of the hospice’s policy and procedure titled “THE PLAN OF CARE” revised on November 2013 indicated “…A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days. This plan will focus on identified problems, goals, and interventions…Any change in the patient’s condition must result in a change in the plan of care, prior to implementation of the new service…””

“Based on observation, interview, and record review, the hospice failed to ensure standard infection control practices were implemented during a bed bath for one of one sampled patient (Patient 1).This failure had the potential for cross-contamination and spread of infection which can adversely affect the health and wellbeing of Patient 1 and staff. Findings: A review of Patient 1’s face sheet (a page in the medical record that contains a summary of basic information about the patient) indicated the patient’s start of care (SOC) was on 7/10/26.A review of the “HA [Hospice Aide] Assignment” dated 7/10/26 indicated instructions for the HA to provide a bed bath, change linens, and tidy the patient’s room. The instructions indicated the skilled nurse instructed the HA to implement safety measures, fall prevention, proper body mechanics, and infection control at all times.During a joint home visit to Patient 1’s home on 7/28/26 at 2:48 PM with HA 1, HA 1 provided the patient with a bed bath. Prior to providing the bed bath, HA 1 performed hand hygiene, donned (put on) a clean pair of gloves, and prepared the supplies. HA 1 filled a plastic basin with soap and water, obtained two clean towels, and placed a clean trash bag at the bottom of the bed. HA 1 undressed Patient 1 and draped a linen over the area not being bathed. HA 1 then washed the body, section by section, starting with the head. HA 1 placed one towel inside the basin, used it to wash the patient’s face, placed the same towel in the basin again, and continued to wash the right side of the patient’s body. HA 1 then hung the wet towel on the basin’s rim. Afterwards, without changing gloves, HA 1 used a different towel to dry the patient and placed the used towels inside the trash bag. Before washing the patient’s left upper body, HA 1 sanitized his hands, donned a new pair of gloves, and obtained clean towels. HA 1 proceeded to place one towel inside the same basin, used the wet towel to wash the patient’s underarm, placed it back in same basin, and continued to reuse the same towel to finish washing the patient’s left upper body. HA 1 then moved the soiled brief underneath the patient and continued with the bed bath. Without changing gloves, HA 1 used the other towel to dry the patient. The used towels and gloves were then placed inside the trash bag. HA 1 then sanitized his hands, donned a new pair of gloves, and provided pericare (washing the private parts and anal area) using the same process without changing the contents of the basin and changing gloves prior to drying the patient’s body. After providing pericare, HA 1 removed the gloves, sanitized his hands, and donned a new pair of gloves. HA 1 then tossed the soiled incontinence brief into the trash, proceeded to reposition the patient, and continued washing the patient’s back. HA 1 used the same water in the basin to wet the towel used to wash the patient. HA 1 then placed the linen used to cover the patient in the trash bag, removed his gloves, and sanitized his hands. HA 1 retrieved a clean incontinence brief and placed it on the patient. HA 1 removed the old underpad, went to the closet to retrieve lotion, doffed gloves, and applied lotion on the patient without performing hand hygiene or donning a clean pair of gloves. After dressing the patient, HA 1 then reached into the trash bag and separated the used linens and towels from the discarded underpads and incontinence brief before placing them into separate receptacles, with his bare hands. HA 1 then proceeded to touch the bathroom doorknob to dispose of the water inside the basin.During an interview on 7/28/26 at 4:00 PM with HA 1, HA 1 was informed of the findings and was asked about the bed bath process for Patient 1. HA 1 stated he first used a wet towel from the basin to wash a section of the patient’s body. After washing, he placed the wet towel on the rim of the basin and dried the patient using a clean towel. HA 1 acknowledged the findings and verified that he used the same basin to clean Patient 1 throughout the bed bath.A review of the hospice’s policy and procedure (P&P) titled “STANDARD PRECAUTIONS” revised on November 2013 indicated “…Hand hygiene will be performed to prevent cross-contamination between the patient and personnel…When hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands…An alternative to use of an alcohol based hand rub is to wash hands with an antimicrobial soap and water…Gloves and other appropriate personal protective equipment are to be worn when handling soiled linen…”A review of the hospice’s P&P titled “HAND HYGIENE” revised on November 2013 indicated “…When hands are not visibly soiled, they should be decontaminated using an alcohol-based hand rub. An alternative to use of an alcohol-based hand rub is to wash hands with an antimicrobial soap and water…Hand decontamination using an alcohol-based hand rub should be performed: A. Before having direct contact with patients…C. After contact with a patient’s intact skin…E. When moving from a contaminated body site to a clean body site during patient care...””

“Based on interview and record review, the hospice failed to ensure the “HA [Hospice Aide] Assignment” was updated to reflect the current treatments for one of three sampled patients (Patient 1).This failure created the risk of not providing the necessary services for Patient 1.Findings: A review of Patient 1’s face sheet (a page in the medical record that contains a summary of basic information about the patient) indicated the patient’s start of care (SOC) was on 7/10/26.A review of Patient 1’s “CTI [Certification of Terminal Illness - a document indicating that a patient has a prognosis of six months or less to live if the illness runs its normal course]” dated 7/10/26 indicated the patient was certified for hospice services during the certification period from 7/10/26 to 9/7/26.A review of Patient 1’s “CURRENT TREATMENT/MEDICATION/DME [Durable Medical Equipment] List” indicated an order for silicone cream dated 7/10/26. The order indicated to “apply to wound base sacral [the triangular-shaped bone at the bottom of the spine] pressure ulcer [localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence] during wound care every 7-10 days and as needed for impaired dressing integrity and/or excessive soiling.”A review of the “HA Assignment” dated 7/10/26 indicated the following instructions: “…Pcg [Patient Caregiver], SN [Skilled Nurse], CHHA [Certified Home Health Aide] will apply Calmoseptine [moisture barrier ointment] to red, excoriated [superficial loss of skin layers caused by scratching, rubbing, friction, or moisture] rashes two times per day as needed. Apply Vitamin A&D ointment to dry and/or itchy skin two times per day as needed…”Further review of the “HA Assignment” dated 7/10/26 indicated no documented evidence the application of silicone cream was included in the instructions.During a joint home visit at Patient 1’s home on 7/28/26 at 3:45 PM with Hospice Aide (HA) 1, an interview was conducted with HA 1 and the patient’s PCG. When asked when Calmoseptine was last applied, the PCG stated neither she nor HA 1 had been using the Calmoseptine. The PCG stated she requested to use the silicone cream instead because it was difficult to clean Patient 1’s skin when Calmoseptine was applied. HA 1 further stated that he also applied the silicone cream and only used Calmoseptine when Patient 1’s skin was excoriated. During a concurrent interview and clinical record review with the Director of Patient Care Services (DPCS) on 8/4/25 at 9:08 AM, Patient 1’s “HA Assignment” dated 7/10/26 and “CURRENT TREATMENT/MEDICATION/DME [Durable Medical Equipment] List” were reviewed. The DPCS was informed of the findings and was asked to clarify the orders. The DPCS stated that Patient 1 had orders for both Calmoseptine and silicone cream. The DPCS stated she was aware that the PCG preferred to use the silicone cream; however, the PCG was still encouraged to use the Calmoseptine. When asked if the HAs applied the silicone cream during visits, the DPCS stated yes. The DPCS verified the “HA Assignment” was not updated to reflect the instructions for the HAs to apply silicone cream to Patient 1’s sacral area.A review of the hospice’s policy and procedure titled “ORIENTATION OF HOSPICE PERSONNEL TO ASSIGNED RESPONSIBILITIES” revised on November 2013 indicated “… The hospice aide will understand the duties to be performed and the arrangements for providing services, as stated in the plan of care... Each patient will receive care in accordance with the written plan of care and related instructions... The hospice aide assignment sheet will correlate with the orders on the hospice plan of care...””

“Based on observation, interview, and record review, the hospice failed to ensure the accuracy of physician’s orders for wound care treatment for one of 14 sampled patients (Patient 2). Patient 2 had two different physician’s order for the care of the Stage 4 pressure injury (full thickness tissue loss with exposed bone, tendon or muscle; slough or eschar may be present on some parts of the wound bed; often includes undermining and tunneling) to the sacrococcyx (the region where the sacrum meets the coccyx). This deficient practice placed the patient at risk for wound deterioration and prevention of wound healing.Findings: A review of Patient 2’s face sheet (a document that contains a summary of basic information about the patient) indicated the SOC (start of care) was on 3/12/26. On 7/28/26 at 12:17 PM, a joint home visit was conducted with Licensed Vocational Nurse (LVN) 1 to Patient 2’s home. During the home visit, LVN 1 was observed cleansing Patient 2’s sacrococcyx wound with normal saline (a saltwater solution) and patted it dry with gauze. LVN 1 proceeded to apply Calmoseptine (moisture barrier ointment) to the periwound and afterwards, applied collagen powder and calcium alginate pad (a medical pad used to keep wound moist to speed up healing without sticking to new tissue) to the wound. LVN 1 then covered the wound with absorbent dressing. A review of Patient 2’s “CURRENT TREATMENT/MEDICATION/DME [Durable Medical Equipment] LIST” indicated a physician’s order dated 7/2/26 to treat the patient’s Stage 4 sacrococcyx wound. The order indicated to “...Cleanse with wound cleanser/ normal saline 0.9%, pat dry with gauze, apply calmoseptine to periwound then collagen to wound, followed by calcium alginate then cover with super absorbent silicone dressing. SN [Skilled Nurse] to change dressing every 2-3 days and as needed for loss of integrity or soiling...”Further review of Patient 2’s “CURRENT TREATMENT/MEDICATION/DME LIST” indicated another physician’s order dated 7/13/26, for Dakin’s 0.25% Half Strength Solution (a topical antiseptic liquid used to clean, irrigate, and treat cuts, scrapes, and infected wounds) to cleanse to all open wounds with every dressing change. A review of the Omni Wound Physicians “Progress Notes” dated 7/23/26 indicated the treatment plan for the sacrococcyx wound was as follows: “...Cleansing Wound Solutions: Sterile Normal Saline. Pat Dry; Calmoseptine to periwound. Apply collagen to wound, followed by calcium alginate, then cover with Super Absorbent Silicone Dressing; Dressing change frequency: every two days and PRN [as needed] for loss of integrity/Soiling...”During a concurrent interview and clinical record review on 8/4/26 at 9:04 AM with the Administrator (Admin), Patient 2’s “CURRENT TREATMENT/MEDICATION/DME LIST” and Omni Wound Physicians “Progress Notes” dated 7/23/26 were reviewed. The Admin verified that the sacrococcyx wound should be treated with normal saline. The Admin stated the Dakin’s solution order should have been clarified with the wound care physician. The Admin added that clarifying the order for wound care helps ensure wound healing and prevents worsening of wounds.A review of the hospice’s policy and procedure titled “Verification of Physician Orders,” revised on November 2013, indicated “...a qualified individual will review each order or prescription before care is provided... An order or prescription will be verified when there is a question or discrepancy in the order or prescription...””

“Based on interview and record review, the hospice failed to ensure the clinical record was completed accurately for one of six sampled patients (Patient 4) when the Bereavement Coordinator (BC) failed to ensure the correct patient was identified in the “Post Death Bereavement” assessment.This failure resulted in inaccurate documentation, misidentification of the deceased, and compromised the accuracy and integrity of the medical record.Findings: A review of Patient 4’s face sheet (a page in the medical record that contains a summary of basic information about the patient) indicated the patient’s start of care (SOC) was on 3/14/26. A review of Patient 4’s “Visit Note Death Visit” dated 6/21/26 indicated the patient passed away on 6/21/26.A review of Patient 4’s “Post Death Bereavement” dated 7/6/26 indicated the BC completed a bereavement assessment. The assessment indicated the hospice’s bereavement services were discussed with Patient 4’s daughter. However, the narrative note indicated the BC identified a different patient.During a concurrent interview and clinical record review with the Director of Patient Care Services (DPCS) on 8/4/26 at 9:14 AM, Patient 4’s “Post Death Bereavement” assessment dated 7/6/26 was reviewed. The DPCS verified the BC identified a different patient under the narrative section of the bereavement assessment.A review of the hospice’s policy and procedure titled “ENTRIES INTO THE CLINICAL RECORD” revised on November 2013 indicated “…Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided…Entries into the clinical record will be clear, concise, and specific statements of fact…””