Dynamic Hospice and Palliative Care

“Upon patient record review, 1 of 19 (Patient #4) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #4: There is evidence of an order for MiraLAX 17 gram powder once a day PRN. The instructions do not include to mix with a diluent.”

“Upon patient record review, 1 of 19 (Patient #1,5) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #1,5: There is no evidence the initial bereavement assessment was completed as part of a comprehensive assessment.”

“Upon patient record review, 1 of 19 (Patient #2) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #2: There is evidence in a communication note the caregiver telephoned the hospice at 12:01am on 3/4/26 with concerns the patient was in pain. There is no evidence the on call nurse made a visit to the patient home. The nurse telephoned the caregiver. The caregiver commented she was not familiar with the comfort kit. The nurse explained the comfort kit contents and how to draw medication with a syringe over the phone.”

“Upon patient record review, 5 of 19 (Patient #1,2,3,5,8) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #1: There is evidence in the medical record the skilled nurse frequency ordered: SN 2x/wk and 3 PRN weekly for assessment, symptom management and change in condition. The PRN frequency is too great. Patient #2,3,5,8: There is evidence in the medical record the skilled nurse frequency ordered: SN 2xwk and 3 PRN weekly for assessment, symptom management and change in condition. The PRN frequency is too great.”

“Upon patient record review, 3 of 19 (Patient #17,18,19) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #17,18,19: There is evidence in the bereavement record the patient refused further services and the agency sent mailings only. The bereavement plan of care did not contain the mailings/letters that were sent.”

“Upon patient record review, 1 of 19 (Patient #6) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #6: There is evidence the patient is on Eliquis 2.5 mg BID. The aide plan of care does not include bleeding precautions.”

“Upon patient record review 1 of 19 (Patient #3) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient #3: There is evidence of an Aide visit on 1/29/26. There is no evidence of a supervisory visit by the nurse from 1/29/26 to present.”

“Based on observation, interview and record review, the Hospice Agency (HA) failed to ensure the Conditions of Participation for Initial and Comprehensive Assessments of Patients was met as follows: Hospice Agency (HA) staff failed to conduct an accurate comprehensive assessment that reflected the patient’s current health status and identify patients’ need for hospice care and services related to management of terminal illness for two of nineteen sample selected patients (Patient 16 and Patient 18). This failure resulted in certified patients not receiving appropriate hospice care and services that could affect their quality of life. (Refer to L 522). HA failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) complete the comprehensive assessment no later than 5 calendar days after hospice election for two of nineteen sample selected patients (Patient 4 and Patient 9). This failure has the potential to result in the patient/family hospice needs will not be identified delaying the development of the plan of care to address these needs and not provided appropriate hospice care to these certified patients that could affect their quality of care. (Refer to L 523). HA failed to review all medications the patients were taking and update their medication profiles with the currently used medications for three of nineteen sample selected patients (Patient 6, Patient 7 and Patient 17). The patients were at risk for medication errors and adverse drug reactions. (Refer to L 530). The HA failed to conduct bereavement assessment to provide bereavement counseling in accordance with the patient/family’s needs for three of nineteen sample selected patients (Patient 1, Patient 6, Patient 7), which focused on the social, spiritual, and cultural factors that may affect the ability of the family and other individuals involved in the care, to cope with the patients death. (Refer to L 531). The HA failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) met and updated the comprehensive assessment at least every 15 days for four of nineteen sample selected patients (Patient 2, Patient 3, Patient 5, Patient 10). This failure has the potential for patients’ response to care, treatment, and services will not be identified and documented in the clinical record for continued hospice care, intervention and accurate care planning decisions and implementation. (Refer to L 533). The cumulative effect of these systemic practices resulted in the failure of the Hospice to deliver statutorily mandated compliance with the Federal regulations for Initial and Comprehensive of Patients to ensure highest quality of care are provided to patients certified to receive the Medicare hospice benefits.”

“Based on interview and record review, the Hospice Agency (HA) failed to meet the Condition of Participation for Interdisciplinary group, Care planning, and Coordination of services as follows: 1. The HA failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) developed and individualized plan of care for one of nineteen sample patients (Patient 9). (Refer to L543). 2. The HA failed to provide written instructions related to care and treatments while receiving anticoagulant (medication to prevent and treat blood clots) and failed to provide education to patient and/or patients caregiver regarding seizure safety precautions for two of nineteen sampled patients (Patient 17 and Patient 18). (Refer to L544). 3. The HA failed to ensure the plan of care (POC) was created to reflect the services needed for two of 19 sampled patients (Patient 8 and Patient 18). (Refer to L545). 4. The HA failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) review, revise and document the individualized plan no less frequently than every 15 calendar days for two of 19 sampled patients (Patient 7, Patient 8). (Refer to L552). The cumulative effect of these systemic practices resulted in the failure of the Hospice to deliver statutorily mandated compliance with Federal regulations for Interdisciplinary group, Care planning, and Coordination of services to ensure the highest quality of care are provided to certified patients receiving the hospice benefits.”

“Based on interview and record review the Hospice Agency (HA) staff failed to conduct an accurate comprehensive assessment that reflected the patient’s current health status and identify patients’ need for hospice care and services related to management of terminal illness for two of nineteen sample selected patients (Patient 16 and Patient 18). This failure resulted in certified patients not receiving appropriate hospice care services that could affect their quality of life. During a record review of Patient 16s medical record form titled “;Personal Information” indicated a start of care date of 10/4/2024 with a primary diagnosis of malignant neoplasm of hypopharynx (an abnormal growth of cancer cells in a region of the lower throat), unspecified. During a concurrent interview and record review on 12/5/2024 at 12:05 p.m., with the Director of Patient Care Services (DPCS) of Patient 16s Electronic Medical Record (EMR), titled “;Comprehensive Assessment”, dated 10/4/2024, indicated in the “;Narrative and Disease Trajectory” section “;A tracheostomy (an opening made through the skin of the neck into the trachea to help in breathing, the surgical procedure is called a tracheostomy, the opening is called a stoma, and a tube called a tracheostomy tube is placed in the opening to keep the hole open) was placed on 8/13/2024. The patient is independently performing tracheostoma care 3-4 times daily, using a suction tube to manage hypersecretions (excessive production of bodily secretions including saliva))”. DPCS confirmed and stated that there was no nursing documentation of an assessment that reflected Patient 16s tracheostomy stoma. DPCS stated that comprehensive assessment is the nurses first visit, it entailed baseline assessment and status of the patient, stated that nurses should have assess the current condition of Patient 16s tracheostomy to identify if any issues like signs and symptoms of site infection and its patency. During a concurrent interview and record review with the DPCS of Patient 16s EMR, titled “;Skin Impairment Assessment”, dated 10/4/2024, indicated no nursing documentation of tracheostomy stoma assessment. DPCS stated that any types of patients wounds, including surgical wounds, must be assessed, and included to either their narrative visit notes or skin impairment assessment to monitor for any changes of the stoma condition. During a concurrent interview and record review with the DPCS of Patient 16s EMR, titled “;Visit Note LVN/RN (Licensed Vocational Nurse/Registered Nurse)”, dated 11/14/2024, 11/21/2024, 11/25/2024, 11/28/2024, and 12/2/2024, indicated no nursing documentation of tracheostomy stoma assessments. DPCS stated that any types of patients wounds, including surgical wounds, must be assessed, and included to either their narrative visit notes or skin impairment assessment to monitor for any changes of the stoma condition and to address for any identified problems. During a record review of Patient 18s medical record form titled “;Personal Information” indicated a start of care date of 3/26/2024 with a primary diagnosis of unspecified sequelae of non-traumatic intracerebral hemorrhage (bleeding into the substance of the brain in the absence of trauma or surgery). During a concurrent interview and record review on 12/5/2024 at 12:35 p.m., with the Director of Patient Care Services (DPCS) of Patient 18s Electronic Medical Record (EMR), titled “;Comprehensive Assessment”, dated 3/26/2024, indicated in the “;Narrative and Disease Trajectory” section that Patient 18 with comorbidities (medical conditions in addition to the primary diagnosis) that included G-tube (a tube that surgically inserted through the wall of the abdomen directly into the stomach, it allows air and fluid to leave the stomach and can be used to give medications, liquids, and liquid foods) status. DPCS confirmed and stated that there was no nursing documentation of assessment that reflected Patient 16s G-tube stoma (opening) site. DPCS stated that comprehensive assessment is the nurses first visit, it entailed baseline assessment and status of the patient, stated that nurses should have assess the current condition of Patient 18s G-tube site to identify if any issues like signs and symptoms of site infection and its patency. During a concurrent interview and record review with the DPCS of Patient 18s EMR, titled “;Skin Impairment Assessment”, dated 3/26/2024, indicated no nursing documentation of G-tube stoma assessment. DPCS stated that any types of patients wounds, including surgical wounds, must be assessed, and included to either their narrative visit notes or skin impairment assessment to monitor for any changes of the stoma condition. During a concurrent interview and record review with the DPCS of Patient 18s EMR, titled “;Visit Note LVN/RN (Licensed Vocational Nurse/Registered Nurse)”, last five nurse visits from month of November, indicated no nursing documentation of G-tube stoma assessments. DPCS stated that any types of patients wounds, including surgical wounds, must be assessed, and included to either their narrative visit notes or skin impairment assessment to monitor for any changes of the stoma condition and to address for any identified problems. During a record review of the HAs form titled “;Comprehensive Assessment” revised 4/2020, indicated “;During the comprehensive patient assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patients clinical record, including at least following information, as relevant: G. A physical assessment, including blood pressure, temperature, pulse, respiration, skin, and other relevant data related to pertinent physical findings and the patients terminal illness”. During a record review of the HAs form titled “;Ongoing Assessment” revised 4/2020, indicated “;During each home visit, the Case Manager or other discipline will evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment, the nurse will assess each patient on each visit for: G. Skin integrity”. During a record review of the HAs form titled “;Tracheostomy Care”, undated, indicated “;Assess for excess peristomal (around the opening) secretions, excess intra-tracheal (inside the trachea (large airway opening leads to the lungs)) or soiled tracheostomy dressing and ties, identify factors that influence tracheostomy care which includes infection”. During a record review of the HAs form titled “;Gastrostomy Tube Care and Management”, undated, indicated “;SN (Skilled Nurse) shall assess G-tube insertion site”.”

“Based on interview and record review the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) complete the comprehensive assessment no later than 5 calendar days after hospice election for two of nineteen sample selected patients (Patient 4 and Patient 9). This failure has the potential to result in the patient/family hospice needs will not be identified delaying the development of the plan of care to address these needs and not provided appropriate hospice care to these certified patients that could affect their quality of care. 1.During a record review of Patient 4s medical record form titled “;Personal Information” indicated a start of care date of 3/26/2024 with a primary diagnosis of chronic diastolic congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a record review of Patient 4s medical record form titled “;History of POC (plan of care)/IDG (Interdisciplinary group)” undated, indicate Patient 4s initial comprehensive meeting was held on 4/2/2024. During a concurrent interview and record review on 12/5/2024 at 11:04 a.m., with the Director of Patient Care Services Designee (DD) of Patient 4s Electronic Medical Record (EMR), DD stated patients’ comprehensive assessments should be completed within five days of start of care with all the disciplines (Medical Doctor, Registered Nurse, Spiritual Counselor, Medical Social Worker). DD stated patient individualized plan of care is formulated with all the disciplines input. DD stated Patient 4s individualized plan of care was completed on 4/2/2024. 2.A review of Patient 9s “;Personal Information” record indicated a start of care on 6/12/2024, with a terminal diagnosis of chronic (lasting a long time) respiratory failure (unable to breathe effectively) with hypoxia (low oxygen levels). The record indicated care ended on 6/23/2024 when Patient 9 died. During a concurrent interview and record review on 12/5/2024, at 10:40 a.m., the Director of Patient Care Services (DPCS) reviewed Patient 9s medical records. The DPCS stated the spiritual assessment was not done because the patient had refused spiritual care services. The DPCS stated even though Patient 9 declined, the Spiritual Counselor (SC) was supposed to call the patient, explain their role, and inform the patient of the services that was available. The DPCS stated there was no documented evidence the SC attempted to contact Patient 9. The purpose of the SC to contact the patient was to show spiritual support, to determine the spiritual or mental support needed such as a Rabbi, Pandit, Priest, and so forth. A record review of the HAs document titled, “;Comprehensive Assessment”, dated April 2020, indicated, “;A comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care...”.”

“Based on observation, interview and record review, the Hospice Agency (HA) staff failed to review all medications the patients were taking and update their medication profiles with the currently used medications for three of nineteen sample selected patients (Patient 6, Patient 7, and Patient 17). This failure had the potential to put the patients at risk for medication errors and adverse drug reactions. 1.A review of Patient 6s “;Personal Information” sheet indicated a start of care on 8/2/2024, with a terminal diagnosis of Alzheimers disease (a brain disease that affects memory). On 12/4/2024, at 11 a.m., a joint home visit was conducted with the Registered Nurse 1 (RN 1) at Patient 6’s residence. During a concurrent observation, interview, and record review on 12/4/2024 at 11:20 a.m., RN 1 reviewed the medications Patient 6 was taking and compared them to Patient 6s medication record titled, “;Current Treatment/Medication/DME List”, printed 12/3/2024. The following medications were at home and not listed on the medication record: -Escitalopram (a medication used to treat depression) 10 mg (mg-milligram, unit of measurement) tablet. -Elura (a supplement) 36 mg capsule. Patient 6s caregiver (CG 1) stated Patient 6 had been taking this medication for a year. The following medications were listed on the record and Patient 6 was no longer taking: -Align (a supplement). CG 1 stated Patient 6 was no longer taking this medication and did not remember when she stopped taking it. -A&D skin ointment (cream). During a concurrent observation, interview, and record review on 12/4/2024 at 11:33 a.m., RN 1 reviewed the medications Patient 6 was taking. The following medications were expired: -Aspirin (used to treat pain, prevent blood clots) 81 mg. RN 1 stated the medication had expired in March 2024. CG 1 stated she sometimes gave Patient 6 Aspirin. -Famotidine (to treat stomach upset). RN 1 stated the medication had expired in August 2022. RN 1 stated, “;I need to do a better job of educating them about expired meds (medication)”. RN 1 stated the risks of taking expired medications included undesired side effects such as interference with the function of the medication and the medication will not be as strong (potent), which meant that the patient would not get the full effect of the medication. During an interview on 12/4/2024, at 11:56 a.m., RN 1 stated the skilled nurse was supposed to review the medications every visit to make sure medications were not expired and reconcile with the family and doctor. Reviewing the medications patients were taking and updating their records was important so the care team know their current medication treatment. 2.A review of Patient 7s “;Personal Information” sheet indicated a start of care on 5/3/2024, with a terminal diagnosis of Alzheimers disease (a brain disease that affects memory). On 12/4/2024, at 12:15 p.m., a joint home visit was conducted with the Registered Nurse 1 (RN 1) at Patient 7’s residence. During a concurrent observation, interview, and record review on 12/4/2024 at 12:43 p.m., RN 1 reviewed the medications Patient 7 was taking and compared them to Patient 7s medication record titled, “;Current Treatment/Medication/DME List”, printed 12/3/2024. Medication “;Keflex” (an antibiotic) was listed and Patient 7s caregiver (CG 2) stated Patient 7 was no longer taking. 3.During a record review of Patient 17s medical record form titled “;Personal Information” indicated a start of care date of 11/30/2024, with a primary diagnosis of metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction). During a joint home visit observation, concurrent review, and interview on 12/4/24, at 11:05 a.m., with the Registered Nurse (RN 2) to Patient 17s residence, RN 2 conducted a medication reconciliation of Patient 17s “;Current Treatment/Medication/DME (Durable Medical Equipment) List” against on hand medications, indicated that the following medications were listed active but was not available: -Ativan 0.5 milligrams (mg, unit of weight), take 1 tablet by mouth daily as needed for agitation. - Milk of Magnesia, give 30 milliliters (ml, unit of weight) by mouth at bedtime as needed for constipation. Do not exceed 1 dose in 24 hours. -Nitroglycerin 0.4 mg sublingual (under the tongue) tablet, take 1 tablet by mouth sublingually every 5 minutes x (times) 3 doses as needed for chest pain/angina. Notify MD (Medical Doctor) if no relief after 3rd dose. RN 2 stated that the missing medications were discontinued already and should not be listed in the active medication list anymore. RN 2 stated that it could be an electronic medical record (EMR) glitched. RN 2 stated that Patient 17 was just recently moved to this facility, but the discontinued medications were returned to the office then to the pharmacy for disposal. RN 2 stated that she conducted medication reconciliation on each visit but was not able to notice the discontinued medications listed as active status. RN 2 stated that it is important to review patients medications on each visit to determine if the medications were discontinued, near expiring and to prevent errors. During an interview on 12/5/2024 at 1:05 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated that nurses should conduct medication reconciliation on each visit to ensure that medications are appropriately provided to patients. DPCS stated that it is important for patients to have medications ready at home for immediate use if patients condition started to decline. During a record review of the HAs form titled “;Medication Profile” revised 4/2020, indicated in the policy that “;Patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. The 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 Agency (HA) failed to conduct the bereavement assessment to provide bereavement counseling in accordance with the patient/family’s needs for three of nineteen sample selected patients (Patient 1, Patient 6, and Patient 7). This failure had the potential for the patient/family not being provided social, spiritual, and cultural support that may impact a family member or other individuals ability to cope with the patients death. 1.During a record review of Patient 1s medical record form titled “;Personal Information” undated, indicated a start of care date of 8/29/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a record review of Patient 1s medical record form titled “;POC (plan of care) Summary” dated as of 12/3/2024, indicated “;Focus Areas – Bereavement...”. The form also indicated under “;Frequency of Visit – to assess and evaluate bereavement and grieving risk facto within 5 days of admission.” During a record review of Patient 1s medical record form titled “;History of Bereavement Assessment” undated, indicated there were no entries made. During a record review of Patient 1s medical record form titled “;History of Bereavement POC (plan of care)” undated, indicated there were no entries made. During a concurrent interview and record review on 12/5/2024 at 10:13 a.m. with the Director of Patient Care Services Designee (DD) of Patient 1s Electronic Medical Record (EMR), DD was unable to locate Patient 1s initial bereavement assessment. DD stated Patient 1s initial bereavement assessment was to be completed within five days of start of care to identify the familys bereavement needs. DD stated that Patient 1s husband and daughter might be the bereaved but did not know. DD stated there was no plan in place for Patient 1s husband when Patient 1 passes away. DD stated Patient 1s husband might have poor coping mechanisms. 2.A review of Patient 6s “;Personal Information” sheet indicated a start of care on 8/2/2024, with a terminal diagnosis of Alzheimers disease (a brain disease that affects memory). During a concurrent interview and record review, on 12/5/2024, at 11:03 a.m., the Director of Patient Care Services (DPCS) reviewed Patient 6s medical record. The DPCS stated there was no initial bereavement assessment in the record. The Medical Social Worker or the Spiritual Counselor was supposed to complete the initial bereavement assessment within 5 days of the start of care. The purpose of the assessment was to assess the patient and family needs, coping mechanism, what the patient/family is seeking from hospice care, what support they need when the time comes of the patient passing (dying), what the mortuary needs are, and what needs to happen when the patient passes way. The DPCS stated she did not know why the initial bereavement assessment was not done. 3.A review of Patient 7s “;Personal Information” sheet indicated a start of care on 5/3/2024, with a terminal diagnosis of Alzheimers disease (a brain disease that affects memory). During a concurrent interview and record review, on 12/5/2024, at 12:40 p.m., the DPCS reviewed Patient 7s medical record. The DPCS stated there was no initial bereavement assessment in the record and did not know the reason why it was not done. During a record review of the HAs form titled “;Bereavement Assessment” revised 4/2020, indicated “;The hospice bereavement plan of care will be developed based on an initial assessment of the patient and family/caregiver needs... On admission, the social worker, chaplain, or hospice registered nurse will complete a bereavement risk assessment... Upon completion all bereavement documentation will be filled.” During a record review of the HAs form titled “;Comprehensive Assessment” revised 4/2020, indicated “;A bereavement assessment of the needs of the patients family and other individuals focusing on: the nature of the relationship to the patient; circumstances surrounding the illness/prognosis; behaviors prior to and after the illness/prognosis; survivor needs (social, spiritual, and cultural) that may impact coping skills; potential for pathological grief reactions.””

“Based on interview and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) met and updated the comprehensive assessment at least every 15 days for four of nineteen sample selected patients (Patient 2, Patient 3, Patient 5, and Patient 10). This failure has the potential for patients’ response to care, treatment, and services will not be identified and documented in the clinical record for continued hospice care, intervention and accurate care planning decisions and implementation. 1.During a record review of Patient 2s medical record form titled “;Personal Information” indicated a start of care date of 8/11/2023 with a primary diagnosis of unspecified protein-calorie malnutrition. During a record review on Patient 2s medical record form titled “;POC (plan of care) Summary” dated as of 12/3/2024, indicated “;IDT (interdisciplinary team) to review plan of care every 2 weeks and as needed for change of condition.” During a record review of Patient 2s medical record form titled “;POC (plan of care)/IDG (interdisciplinary group) Review” dated 11/29/2024, indicated there were no documented discussion on the spiritual, psychosocial, and other/physician sections. The form also indicated the Medical Doctor (MD), the MSW (medical social worker) and Spiritual Counselor (SC) signatures were not documented. During a record review of Patient 2s medical record form titled “;POC (plan of care)/IDG (interdisciplinary group) Review” dated 11/15/2024, indicated there were no documented discussion on the spiritual, and other/physician sections. The form also indicated the Medical Doctor (MD), and SC signatures were not documented. During a concurrent interview and record review on 12/5/2024 at 10:20 a.m., with the Director of Patient Care Services Designee (DD) of Patient 2s Electronic Medical Record (EMR), DD stated Patient 2s was currently on her 8th benefit period from 12/3/2024 to 1/31/2025. DD stated nursing recertification assessments are completed every 60 days starting six months after the start of care and no more than 15 days before the benefit period. DD stated Patient 2s 8th recertification nursing assessment was documented after 12/3/2024. DD stated patient’s assessments need to be documented timely to inform involved staff of the patients current status. DD stated the recertification nursing assessment dictates what goes on the patients individualized plan of care, and without a documented assessment the patients plan of care does get updated. DD stated when a patient plan of care is not updated the patient does not receive the care and treatment the physician ordered. During a concurrent interview and record review on 12/5/2024 at 10:35 a.m. with DD of Patient 2s EMR, DD stated the interdisciplinary team (IDT) which consist of the MD, MSW, SC, and DPCS meet every 14 days to update patients condition and make changes to their plan of care if needed. The DD stated each individual discipline documents their findings and sign the day of the meeting. The DD stated the disciplines signatures in the HAs EMR validates their attendance. The DD stated Patient 2s IDG meeting dated 11/29/2024 was attended by nursing and the MD. The DD stated Patient 2s IDG meeting dated 11/15/2024 was attended by nursing, MD and MSW. 2.During a record review of Patient 3s medical record form titled “;Personal Information” indicated a start of care date of 3/24/2024 with a primary diagnosis of Alzheimers Disease (a disease characterized by a progressive decline in mental abilities) with late onset. During a record review of Patient 3s medical record form titled “;POC/IDG Review” dated 11/26/2024, indicated the other/physician discussion and MD signature sections were left blank. During a record review of Patient 3s medical record form titled “;History of Spiritual Assessment” undated, indicated there were no entries made. During a record review of Patient 3s medical record form titled “;History of Visit Notes” undated, indicated there were no entries made by a Spiritual Counselor or Chaplain. During a record review of Patient 3s medical record form titled “;POC Summary” dated as of 12/3/2024, indicated “;Frequency: SC (Spiritual Counselor) services declined at this time, will continue to offer services to family/caregiver.” During a concurrent interview and record review on 12/5/2024 at 10:50 a.m. with the DD of Patient 3s EMR, DD stated there were no communication notes that spiritual services were offered again after Patient 3s start of care. DD stated the SC was supposed to offer their services at every recertification in case patients families change their minds and accept spiritual support. DD stated that spiritual support helps the family find peace with the dying process. DD stated when spiritual support is not offered or provided to the family, the family can experience ineffective cooping and grief mechanisms with unresolved feelings. During a concurrent interview and record review on 12/5/2024 at 11:02 a.m. with the DD of Patient 3s EMR medical record form titled “;POC/IDG Review” dated 11/26/2024, DD stated, “;Looks like the doctor missed the meeting.” 3.During a record review of Patient 5s medical record form titled “;Personal Information” indicated a start of care date of 10/17/2024 and an end of care date of 11/14/2024 with a primary diagnosis of unspecified severe protein calorie malnutrition. During a record review of Patient 5s medical record form titled “;POC Summary” dated as of 12/3/2024, indicated “;IDT to review plan of care every 2 weeks and as needed for change of condition.” During a record review of Patient 5s medical record form titled “;Current Treatment/Medication/DME List” indicated “;IDT to review plan of care every 2 weeks and as needed for change of condition.” During a record review of Patient 5s medical record form titled “;POC/IDG Review” dated 10/31/2024, indicated there was no documentation in the SC discussion section and it was not signed by the SC. During a record review of Patient 5s medical record form titled “;POC/IDG Review” dated 11/14/2024, indicated there was no documentation in the SC discussion section and it was not signed by the SC. During a record review of Patient 5s medical record form titled “;POC/IDG Review” dated 11/28/2024, indicated there was no documentation in the SC or MSW discussion sections and it was not signed by the SC or MSW. 4.A review of Patient 10s record titled, “;Personal Information”, indicated a start of care on 9/1/2022, with a terminal diagnosis of Dementia (a brain condition that affects the daily life). During a concurrent interview and record review on 12/5/2024, at 11:12 a.m., the Director of Patient Care Services (DPCS) reviewed Patient 10s medical records. The DPCS stated the initial spiritual assessment was done by the Spiritual Counselor (SC) on 9/5/2022. The DPCS stated spiritual care services was declined by Patient 10 on 1/10/2023. The DPCS stated there was no documentation spiritual care services were offered again every recertification period. Spiritual services should have been offered every recertification period because the patient might change their mind, have new needs, and need to know that the service was still available to them. If spiritual care services were not offered the HA is not providing complete and holistic care that the program requires. The DPCS stated Patient 10 was recertified eight (8) times after spiritual care services was declined on 1/10/2023. A record review of the HAs document titled, “;The Plan of Care”, April 2020, indicated, “;Policy...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.””

“Based on interview, and record review, the Hospice Agency HA failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) developed and individualized plan of care for one of nineteen sample patients (Patient 9). This failure resulted in care being provided without coordination with the IDG team to ensure the hospice patient’s needs are were met. A review of Patient 9s “;Personal Information” record indicated a start of care on 6/12/2024, with a terminal diagnosis of chronic (lasting a long time) respiratory failure (unable to breathe effectively) with hypoxia (low oxygen levels). The record indicated care ended on 6/23/2024 when Patient 9 died. During a concurrent interview and record review on 12/5/2024, at 10:49 a.m., the Director of Patient Care Services (DPCS) reviewed Patient 9s record titled, “;POC/IDG”, dated 6/25/2024. The DPCS stated this was the first time the IDG group met. The IDG group met after the patient died. The DPCS stated the IDG group should have met to discuss the needs of the patient and caregiver, to develop the plan of care, within 5 days of the start of care. The plan of care should have been developed with input of the IDG team by 6/15/2024. The DPCS stated it was important for the IDG team to create the plan of care to establish the visit frequencies, develop the plan of care based on the needs of the patient. The DPCS stated the plan of care was created by the nurse. During a concurrent interview and record review on 12/5/2024, at 10:52 a.m., the DPCS reviewed Patient 9s record titled, “;POC/IDG”, dated 6/25/2024. The DPCS stated the document did not indicate any input or narrative documented about the MSWs input in the development of the plan of care. The DPCS stated the purpose of documenting the MSWs input was, so the IDG group knows what the needs of the patient are and what the care team needs to follow up on. To make sure the HA is meeting the needs of the patient by offering the support they need. A record review of the HAs document titled, “;The Plan of Care”, April 2020, indicated, “;Procedure...4. The plan of care will identify the patients needs and services to meet those needs...5. The individualized plan of care will be reviewed by the rest of the interdisciplinary group within two (2) days of start of care.”

“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 provide written instructions related to care and treatments while receiving anticoagulant (medication to prevent and treat blood clots), and failed to provide education to patient and/or patients caregiver regarding seizure safety precautions for two of nineteen sampled patients (Patient 17 and Patient 18). This deficient practice had the potential to result in the patient’s and/or patient caregivers lack of knowledge to observe safety and report for any significant signs and symptoms manifested while taking this medication. During a review of Patient 17s “;Personal Information”, indicated a start of care (SOC) date of 11/30/2023, with a primary diagnosis of metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction). During a review of Patient 17s “;Plan of Care (POC, a written document developed for each individual by the support team using a person-centered approach that describes the supports, services, and resources provided or accessed to address the needs of the individual)”, the POC indicated in the Neurological (nervous system that includes the brain, spine and nerves)/Mental” section, “;seizure-like episodes secondary to metabolic encephalopathy, under “;Intervention”, “;to provide safe/hazard free environment”. During a concurrent joint home visit observation, and interview on 12/4/2024, at 11:05 a.m., with Registered Nurse (RN 2) 2, at Patient 17s private room, Patient 17 was observed lying in bed, comfortably sleeping, and responds only when her name was called. RN 2 stated that Patient 17 has a comorbidity (disease in addition to the primary diagnosis) that includes seizure (is a burst of uncontrolled electrical activity between brain cells (also called neurons or nerve cells) that causes temporary abnormalities in muscle tone or movements (stiffness, twitching or limpness), behaviors, sensations, or states of awareness). RN 2 stated that Patient 17 has multiple episodes of seizures recently, stated that she provided teachings to caregivers regarding safety precautions during seizure episodes such as applying padding at side rails, protecting patients head, place patient on side lying position to prevent from aspiration and to prevent patient from falling on bed. RN 2 stated that side rails paddings were not necessary because Patient 17 is bed bound and immobile. RN 2 stated that she was unsure if she documented it in her nursing notes. RN 2 stated that it is important to provide teachings to patients and their caregivers since the nurses are not around every time. During a concurrent interview and record review on 12/5/2024 at 12:15 p.m., with the Director of Patient Care Services (DPCS) of Patient 17s Electronic Medical Record (EMR), titled “;Visit Note RN (Registered Nurse)”, dated 11/16/2024, 11/19/2024, 11/23/2024, 11/27/2024, and 11/29/2024, the DPCS confirmed there was no nursing documentation that teaching was provided regarding safety precautions during seizure episode. DPCS stated that the nurses should document of the provided teaching and documentation must be accurate so that there will be no miscommunication between staff and patients. DPCS stated that nurses should document if teaching was provided to patient/caregiver/facility staff regarding a particular task to validate that it was done. DPCS stated that seizure safety precautions include side rails have to attached padding regardless of mobility status. During a record review of Patient 18s medical record form titled “;Personal Information” indicated a start of care date of 3/26/2024 with a primary diagnosis of unspecified sequelae of non-traumatic intracerebral hemorrhage (bleeding into the substance of the brain in the absence of trauma or surgery). Treatment/Medication/DME (Durable Medical Equipment) List”, indicated an order dated 11/25/2024 with start date of 3/26/2024 included Eliquis (anti-coagulant medication) 2.5 milligram (mg, unit of weight) twice daily to prevent blood clots/stroke. DPCS stated that the medication has risk for bleeding and teaching should be provided to patients/caregivers and/or families on what to look for while on this medication. During a concurrent interview and record review with the DPCS of Patient 18s EMR, titled “;Visit Note LVN/RN (Licensed Vocational Nurse/Registered Nurse)”, last five nurse visits from month of November, indicated no nursing documentations that teachings were provided regarding bleeding precautions while on anti-coagulant medication. DPCS confirmed there was no nursing documentation that teaching was provided regarding bleeding precautions. DPCS stated that the nurses should document of the provided teaching and documentation must be accurate so that there will be no miscommunication between staff and patients. DPCS stated that nurses should document if teaching was provided to patient/caregiver/facility staff regarding a particular task to validate that it was done. During a record review of the HAs form titled “;Patient Education Process” revised 4/2020, indicated “;Patients and family/caregivers will receive education in verbal, visual, and written format, as appropriate. 7). Documentation of patient and family/caregiver education will consist of: A. Describing what was taught to the patient (if using preprinted materials, document the name of the handout), B. Describing the patients response to the teaching, including the level of understanding and the ability to repeat or demonstrate what was taught. C. Describing any additional learning needs not currently met and D. Describing teaching planned for subsequent visits”.”

“Based on interview and record review, the Hospice Agency (HA) failed to ensure the plan of care (POC) was created to reflect the services needed for two of 19 sampled patients (Patient 8 and Patient 18). This failure resulted in the delay of care, which can lead to an increase mental and emotional stress to patient and or family member. 1.A review of Patient 8s record titled, “;Personal Information”, indicated a start of care on 10/11/2024, with a terminal diagnosis of multiple myeloma (a type of cancer in the blood). During a concurrent interview and record review on 12/5/2024, at 10:04 a.m., the Director of Patient Care Services (DPCS) reviewed Patient 8s record titled, “;Psychosocial Assessment”, dated 10/15/2024. The DPCS stated the assessment indicated Patient 8s caregiver was overwhelmed with care. The caregiver needed increased caregiver hours. During a concurrent interview and record review on 12/5/2024, at 10:06 a.m., the DPCS reviewed Patient 8s record titled, “;POC/IDG”, dated 10/17/2024. The DPCS stated The IDG group IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) met on 10/17/24. The MSW was supposed to document the key points of the assessment and what the needs of the patient were. The DPCS stated the IDG group verbally discussed it, but it was not documented. The purpose of documenting the discussion was for the entire team know what is going on with the patient, so that the care team are able to follow the care. The documentation validates the care that was given to the patient. A review of Patient 8s record titled, “;Communication Log”, with dates from 10/11/2024 to 12/4/2024, indicated the Medical Social Worker (MSW) had spoken to Patient 8s caregiver on 10/19/2024 and had agreed to volunteer services. A review of Patient 8s record titled, “;Communication Log”, with dates from 10/11/2024 to 12/4/2024, indicated the MSW contacted the Volunteer Coordinator (VC) on 10/21/2024, and the VC would follow up directly with Patient 8s caregiver. A review of Patient 8s record titled, “;Communication Log”, with dates from 10/11/2024 to 12/4/2024, indicated the MSW spoke to the VC on 10/31/2024, to follow up on referral for volunteer services. A review of Patient 8s record titled, “;Communication Log”, with dates from 10/11/2024 to 12/4/2024, indicated the MSW followed up with Patient 8s caregiver to discuss referrals for additional caregiving services as well as volunteer services. A review of Patient 8s record titled, “;Communication Log”, with dates from 10/11/2024 to 12/4/2024, indicated the MSW contacted Patient 8s caregiver on 12/4/2024 and discussed volunteer services would likely begin the week of 12/16/2024. During a concurrent interview and record review on 12/4/2024, at 10:33 a.m., the DPCS reviewed Patient 8s medical records. The DPCS stated the IDG group was aware of the volunteer needs and challenges in getting the right volunteer based on the patient preferences. The discussions we had about the volunteer service this patient needed, were not documented. Documentation was important because it shows what we have done, to get a clear picture of the patient care. That we have discussed the needs and what interventions have been done. The DPCS stated the plan of care was no updated to reflect Patient 8s need of volunteer services. The DPCS stated it was important to update the plan of care because it is where everything we need to do for the patient is written. How we are supposed to be supporting them: medical, psychosocial, spiritual, volunteer. If the plan of care is not updated the patients care is incomplete. If we are doing something, we are supposed to document what we are doing to support the patient as a whole. During an interview on 12/5/2024 at 10 a.m., the DPCS stated volunteer services had not begun for Patient 8 because the VS wanted to find the right fit for the patient. The DPCS stated there was no documentation that the VC contacted Patient 8s family to assess what the right fit was. The DPCS stated there was no documentation of the interventions the HA had done, of what had been done in attempting to get volunteer services for Patient 8. The DPCS stated from the initial request of 10/21/24 to the present time, this was not appropriate. At the most, the patient should receive volunteer services within 2 weeks of request because the patients needs warrants services sooner, rather than later. If volunteer needs are not met the patient can get disappointed, feel not heard, not listened to. The DPCS stated it looked like we are not doing what we promised. We are not providing the support the patient needs: psychosocial and emotional support. 2.During a record review of Patient 18s medical record form titled “;Personal Information” indicated a start of care date of 3/26/2024 with a primary diagnosis of unspecified sequelae of non-traumatic intracerebral hemorrhage (bleeding into the substance of the brain in the absence of trauma or surgery). During a concurrent interview and record review on 12/5/2024 at 12:45 p.m., with the Director of Patient Care Services (DPCS) of Patient 18s Electronic Medical Record (EMR), titled “;Comprehensive Assessment”, dated 3/26/2024, indicated in the “;Narrative and Disease Trajectory” section that Patient 18 with comorbidities (medical conditions in addition to the primary diagnosis) that include G-tube (a tube that surgically inserted through the wall of the abdomen directly into the stomach, it allows air and fluid to leave the stomach and can be used to give medications, liquids, and liquid foods) status. DPCS confirmed and stated that there was no nursing documentation of assessment that reflects Patient 16s G-tube stoma (opening) site. DPCS stated that comprehensive assessment is the nurses first visit, it entailed baseline assessment and status of the patient, stated that nurses should have assess the current condition of Patient 18s g tube site to identify if any issues like signs and symptoms of site infection and its patency. During a concurrent interview and record review with the DPCS of Patient 18s EMR, titled “;POC (Plan of Care)/IDG (Interdisciplinary Group Review”, dated 11/26/2024, and Plan of Care (POC), dated 12/5/2024, indicated no care plan regarding G-tube stoma (opening) site. DPCS stated that any identified patients comorbidities of any types need to have an individualized care plan to address for any potential problems and collaboration of care among the IDG team. During a record review of the HAs form titled “;The Plan of Care” revised 4/2020, indicated “;A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program”.”

“Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) review, revise, and document the individualized plan no less frequently than every 15 calendar days for two of 19 sampled patients (Patient 7 and Patient 8). This failure had the potential to result in patients’ progress or decline will not be coordinated to the members of the IDG to update information on the POC for further intervention and palliation (medical care that relieves symptoms). 1.A review of Patient 7s “;Personal Information” sheet indicated a start of care on 5/3/2024, with a terminal diagnosis of Alzheimers disease (a brain disease that affects memory). During an observation of the home visit on 12/4/2024, at 12:15 p.m., Patient 7 had a collection bag at the right side of the bed, draining clear yellow urine. During an interview at the home visit on 12/4/2024, at 12:20 p.m., Registered Nurse 1 (RN 1) stated the bag was a Foley catheter (a tube that drains urine from the bladder). During an interview at the home visit on 12/4/2024, at 12;21 p.m. Patient 7s caregiver (CG 2) stated there were issues with the catheter being blocked and resulted in changing the catheter every two weeks. During an interview at the home visit on 12/4/2024, at 12:25 p.m., RN 1 stated Patient 7s catheter used to be changed every month. As of 1 month ago, the catheter gets changed every 2 weeks. During an interview on 12/5/2024, at 12:15 p.m., the Director of Patient Care Services Designee (DD) stated a new order was given on 11/6/2024 to change the catheter frequency change from monthly to every 2 weeks. The DD stated the plan of care was supposed to be updated the same day or at least at the IDG meeting. During a concurrent interview and record review on 12/5/2024, at 12:16 p.m., the DD reviewed Patient 7s record titled, “;POC/IDG”, dated 11/12/2024. The DD stated plan of care (POC) indicated to change the catheter monthly. In this document, the new order of 11/6/24 appeared to let us know the new order. The DD stated the “;monthly” intervention was not removed. This could create confusion. During a concurrent interview and record review on 12/5/2024, at 12:18 p.m., the DD reviewed Patient 7s record titled, “;POC/IDG”, dated 11/26/2024. The DD stated the document still said to change the catheter monthly. The DD stated it was important to update the POC, so everyone is aware on what needs to be monitored. To know how often to change the Foley catheter bag. Since the frequency changed to every 2 weeks, the patient is at greater risk of infection. The more you change the catheter, the greater the risk of infection. Infection prevention control was important. 2.A review of Patient 8s record titled, “;Personal Information”, indicated a start of care on 10/11/2024, with a terminal diagnosis of multiple myeloma (a type of cancer in the blood). During a concurrent interview and record review on 12/5/2024, at 10:12 a.m., the Director of Patient Care Services (DPCS) reviewed Patient 8s records titled, “;Visit Note MSW”, dated 11/11/2024 and “;POC/IDG”, dated 11/14/2024. The DPCS stated “;Visit Note MSW” indicated there was some engagement with the patient. In the initial psychosocial assessment (10/15/24), Patient 8 was drowsy. The DPCS stated the” POC/IDG” note of 11/14/2024 indicated the MSW remained in contact with the patient and family regarding the plan of care. During a concurrent interview and record review on 12/5/2024, at 10:15 a.m., the DPCS reviewed Patient 8s record titled, “;POC/IDG”, dated 11/11/2024. The DPCS was asked how the IDG group was informed about the psychosocial visits, needs of the patient and caregiver, and support provided on the MSWs visit of 11/11/2024. The DPCS stated the MSW should have documented the update of the visit. The update that the MSW was able to communicate with the patient. This was important because there was a change of condition. Initially, Patient 8 was drowsy, and on 11/11/2024, Patient 8 was able to communicate and get a better perspective of the patients experience because there was interaction. Its the patient we are treating, if they are making contact, we should know when patient is alert and interactive. So, we know if there is a certain time of day when the patient is awake, we could schedule visits around that time. To interact with the patient and get a better understanding of their perception/needs. A record review of the HAs document titled, “;The Plan of Care”, April 2020, indicated, “;Policy...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.””

“Based on interview and record review the Hospice Agency (HA) failed to ensure the medical director and/or physician designee conducted a review and verify the patients clinical information to determine patient needs of recertification of terminal illness for continued hospice care and services for one of nineteen sample selected patients (Patient 4). This failure resulted in the hospice claiming reimbursement for patients who did not need hospice care and service management of terminal illness and had the potential of the patients not receiving appropriate hospice care services that could affect their quality of life. During a record review of Patient 4s medical record form titled “;Personal Information” indicated a start of care date of 3/26/2024 with a primary diagnosis of chronic diastolic congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a record review of Patient 4s medical record form titled “;F2F (face to face) Visit Notes List” indicated the last entry was made on 9/30/2024. During a record review of Patient 4s medical record form titled “;Physicians Certification for Hospice Benefit (CTI)” dated from 12/1/2024 to 1/29/2025, indicated “;I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment, and/or examination of the patient.” The form also indicated the physician narrative was left blank, and it was not signed by a physician. During a concurrent interview and record review on 12/5/2024 at 11:04 a.m., with the Director of Patient Care Services Designee (DD) of Patient 4s Electronic Medical Record (EMR), the DD stated Patient 4s current CTI dated 12/1/2024 to 1/29/2025 was not signed by a physician. The DD stated a patient’s CTI determines the patient is terminally ill and qualifies for hospice benefits. DD stated the Nurse Practitioner (NP1) documented Patient 4s face to face encounter on 12/4/2024. A record review of the HAs document titled, “;Certification of Terminal Illness”, dated April 2020, indicated, “;Procedure...The hospice Medical Director and the patients attending physician will sign the certification of terminal illness and authorization for hospice services forms.””

“Based on interview and record review the Hospice Agency (HA) failed to ensure any amendments, correction or late entries within an electronic health record must clearly identify the original content, the modified content, date, and authorship of each record modification for six of nineteen sample selected patients (Patient 2, Patient 4, Patient 6, Patient 7, Patient 9, and Patient 11). This failure has the potential to result in an unauthorized and inaccurate patient information or assessment will be entered in the patients clinical records that could affect the patients quality of care and well-being. 1.During a record review of Patient 2s medical record form titled “;Personal Information” indicated a start of care date of 8/11/2023 with a primary diagnosis of unspecified protein-calorie malnutrition. During a record review of Patient 2s medical record form titled “;History of Nursing Assessment” indicated the last entry was made on 9/30/2024. During a record review of Patient 2s Electronic Medical Record (EMR), medical record form titled “;History of Visit Notes” indicated the last Registered Nurse (RN) note was entered on 11/11/2024. During a record review on Patient 2s medical record form titled “;POC (plan of care) Summary” dated as of 12/3/2024, indicated the last physician order was documented on 9/30/2024, “;Patient has met qualifications per... and will be re-certified to continue hospice services effective for the cert period of 10/04/2024-12/02/2024...”. During a concurrent interview and record review on 12/5/2024 at 10:20 a.m., with the Director of Patient Care Services Designee (DD) of Patient 2s Electronic Medical Record (EMR), DD stated Patient 2s was currently on her 8th benefit period from 12/3/2024 to 1/31/2025. DD stated nursing recertification assessments are completed every 60 days starting six months after the start of care and no more than 15 days before the benefit period. DD stated Patient 2s 8th recertification nursing assessment was documented after 12/3/2024. DD stated HA staff have seven days to document their visits. DD stated patient’s assessments need to be documented timely to inform involved staff of the patient’s current status. DD stated the recertification nursing assessment dictates what goes on the patients individualized plan of care, and without a documented assessment the patients plan of care does get updated. DD stated when a patient plan of care is not updated the patient does not receive the care and treatment the physician ordered. 2.During a record review of Patient 4s medical record form titled “;Personal Information” indicated a start of care date of 3/26/2024 with a primary diagnosis of chronic diastolic congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a record review of Patient 4s medical record form titled “;F2F (face to face) Visit Notes List” indicated the last entry was made on 9/30/2024. During a record review of Patient 4s medical record form titled “;Audit Log...” dated from 12/1/2024 to 12/5/2024, indicated Nurse Practitioner 1 (NP1) documented and signed Patient 4s MD (Medical Doctor) Visit Note dated 11/19/2024, on 12/4/2024. During a concurrent interview and record review on 12/5/2024 at 11:04 a.m., with the Director of Patient Care Services Designee (DD) of Patient 4s Electronic Medical Record (EMR), the DD stated the Nurse Practitioner (NP1) documented Patient 4s 11/19/2024 face to face encounter on 12/4/2024. The DD stated NP1 was late documenting Patient 4s face to face encounter. The DD stated Patient 4 lives at home and does not have anything that states NP1 visited Patient 4 on 11/19/2024. 3.A review of Patient 6s “;Personal Information” sheet indicated a start of care on 8/2/2024, with a terminal diagnosis of Alzheimers disease (a brain disease that affects memory). During an interview on 12/5/2024, at 10:52 a.m., the Director of Patient Care Services (DPCS) stated signatures on the document titled “;POC/IDG” indicated the presence and participation of the IDG group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families). During a concurrent interview and record review on 12/5/2024, at 11:01 a.m., the DPCS reviewed Patient 6s record titled, “;POC/IDG”, dated 11/26/2024. The DPCS stated the document was not signed by the doctor. 4.A review of Patient 7s “;Personal Information” sheet indicated a start of care on 5/3/2024, with a terminal diagnosis of Alzheimers disease (a brain disease that affects memory). During a concurrent interview and record review on 12/5/2024, at 11:11 a.m., the DPCS reviewed Patient 7s record titled, “;POC/IDG”, dated 11/26/2024. The DPCS stated the document was not signed by the doctor. 5.A review of Patient 9s “;Personal Information” record indicated a start of care on 6/12/2024, with a terminal diagnosis of chronic (lasting a long time) respiratory failure (unable to breathe effectively) with hypoxia (low oxygen levels). The record indicated care ended on 6/23/2024 when Patient 9 died. During a concurrent interview and record review on 12/5/2024, at 10:52 a.m., the DPCS reviewed Patient 9s record titled, “;POC/IDG”, dated 6/25/2024. The DPCS stated the document did not indicate any input or narrative documented about the Medical Social Workers (MSW) input in the development of the plan of care. The DPCS stated the purpose of documenting the MSWs input was, so the IDG group knows what the needs of the patient are and what the care team needs to follow up on. To make sure the HA is meeting the needs of the patient by offering the support they need. The DPCS stated the document did not indicate the signature of the MSW and doctor. The signature indicated their presence and participation in the IDG meeting. The DPCS stated the IDG members needed to sign the document within 5 days of the meeting. 6.During a review of patient 11s “;admission record” it indicated a start of care (SOC) date of 7/26/24 with a terminal diagnoses of Atherosclerotic heart disease (hardening of your arteries from plaque buildup) of the coronary arteries. During a review of patient 11s “;plan of care summary” dated 12/4/24 it indicated the frequency of visits of skilled nursing (SN) is 2 per week, Health Aide (HA) 2 per week, Master of Social Work (MSW) 1 per month. During a review of Patient 11s “;Physicians Certification for Hospice Benefit (CTI) dated 7/26/24 it indicated that this document was never actually signed by the referring physician. During an interview on 12/5/24 at 12:40 p.m., with the Director of Patient Care Services (DPCS) she stated that the referring physician was notified to sign the initial CTI for Patient 11 a few times, but the agency failed to obtain a signature. During a review of the agencys policy entitled “;Certification of Terminal Illness” dated April 2020 it indicated the hospice medical director and the patients attending physician will sign the certification of terminal illness and authorization for hospice services forms.”