A1 Pro Hospice Care

“It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient’s attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by clinical record review, document review, and interviews which revealed the hospice: Failed to ensure that each patient’s individualized written plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care {HCPC.21. I/L548/418.56(c)(3)}; Failed to ensure interventions for problems identified in the initial and updated comprehensive assessments were included in the plan of care {HCPC.21.I/L545/418.56(c)}; and Failed to ensure that each plan of care included treatments to meet the patient’s needs {HCPC.21.I/549 418.56(c)(4)}. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation, CFR 418.56: Interdisciplinary group, care planning, and coordination of service. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the hospice agency.”

“It is required that all hospice aides provided services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by clinical records review, document review, observation, and interview with the Administrator/Director of Nursing which revealed the hospice agency: Failed to ensure that all pertinent patient care instructions and safety precautions were included in the written instructions prepared for the hospice aide {HCDT.15.I/ L625/ 418.76(g)(1)}. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.76, Hospice Aide Services. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the organization did not ensure interventions for problems identified in the initial and updated comprehensive assessments were included in the plan of care. CLINICAL RECORD 1: The patient elected the hospice benefit on 06/21/2026 and was discharged alive, no longer terminally ill, on 07/31/2026. The patient’s primary and pertinent secondary diagnoses included degenerative disease of the nervous system, encounter for fitting and adjustment of urinary device (suprapubic catheter), dysphagia, epilepsy, and stage 3 pressure ulcer of the sacral region. The patient resided in a board and care. The hospice plan of care (POC) effective 06/21/2026 was noted to include a physician’s order for Levetiracetam 750 mg 1 tablet every 12 hours, for the prevention of seizures. The POC did not include any interventions or precautions for the seizures. During a joint clinical record review and interview on 08/27/2026, the ARNP Clinical Manager confirmed that the POC effective 06/21/2026 included no interventions or precautions for seizures. The ARNP stated, “The POC should have planned interventions for seizures to protect the patient from injury.””

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following: measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 14 of 14 (100%) clinical records reviewed, the organization did not ensure that each patient’s individualized written plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 1: The patient elected the hospice benefit on 06/21/2026 and was discharged alive, no longer terminally ill, on 07/31/2026. The primary and pertinent secondary diagnoses included degenerative disease of the nervous system, encounter for fitting and adjustment of urinary device (suprapubic catheter), dysphagia, epilepsy, and stage 3 pressure ulcer of the sacral region. The hospice plan of care (POC) effective 06/21/2026 was noted to include the following non-measurable outcome for a problem identified as “Comfort”: “Pt will maintain comfort while on hospice.” The clinical record did not include a definition of comfort as defined by the patient and did not identify specific interventions that would be performed by the IDT for the patient to achieve patient-defined comfort. CLINICAL RECORD 2: The patient elected the hospice benefit on 08/24/2024 and was discharged alive, no longer terminally ill, on 07/24/2026. The primary and pertinent secondary diagnoses included senile degeneration of the brain, metabolic encephalopathy, and a wound on the patient’s left lower leg. The hospice POC effective 06/15/2026 was noted to include the following non-measurable outcome for the problem identified as “Comfort”, originally identified on 08/24/2024: “Pt will maintain comfort while on hospice.” The clinical record did not include a definition of comfort as defined by the patient and did not identify specific interventions that would be performed by the IDT for the patient to achieve patient-defined comfort. CLINICAL RECORD 3: The patient elected the hospice benefit on 05/18/2026 and was discharged alive after revoking the hospice benefit to seek aggressive treatment on 06/02/2026. The patient’s primary and pertinent secondary diagnoses included chronic right heart failure, severe pulmonary hypertension, recurrent deep vein thrombosis with nonadherence to anticoagulation therapy, and a history of long-term cocaine abuse. The hospice POC effective 06/21/2026 was noted to include the non-measurable outcome statement for two problems; the first identified as “Comfort” and the second identified as “Pain”: “Pt will maintain comfort while on hospice.” The hospice POC did not include a definition of comfort as defined by the patient and did not identify specific interventions that would be performed by the IDT for the patient to achieve patient-defined comfort. The POC included pain interventions but did not include the patient-specific measurable pain outcomes identified in the comprehensive assessment. CLINICAL RECORD 4: The patient elected the hospice benefit on 05/26/2026 and was discharged alive after revoking the hospice benefit to seek aggressive treatment on 05/31/2026. The patient’s primary and pertinent secondary diagnoses included senile degeneration of the brain, dementia, Parkinson’s disease, Type 2 diabetes mellitus, hypertension, and anxiety. The hospice POC effective 05/26/2026 was noted to include the non-measurable outcome statement for two problems; the first identified as “Comfort” and the second identified as “Pain”: “Pt will maintain comfort while on hospice.” The POC did not include a definition of comfort as defined by the patient and did not identify specific interventions that would be performed by the IDT for the patient to achieve patient-defined comfort. The POC included pain interventions but did not include the patient-appropriate measurable pain outcomes identified in the comprehensive assessment. CLINICAL RECORD 5: The patient elected the hospice benefit on 05/06/2026 and was transferred/discharged alive to another hospice on 05/07/2026. The patient’s primary terminal diagnosis was Parkinson’s disease with dyskinesia. The hospice POC effective 05/06/2026 was noted to include the non-measurable outcome statement for two problems; the first identified as “Comfort” and the second identified as “Pain”: “Pt will maintain comfort while on hospice.” The POC did not include a definition of comfort as defined by the patient and did not identify specific interventions that would be performed by the IDT for the patient to achieve patient-defined comfort. The POC included pain interventions but did not include the patient-appropriate measurable pain outcomes identified in the comprehensive assessment. CLINICAL RECORD 6: The patient elected the hospice benefit on 07/29/2026 and died at home on 08/03/2026. The patient’s primary and pertinent secondary diagnoses included malignant neoplasm of the upper lobe of the left bronchus and lung with metastases to the brain, bone, and stomach. The hospice POC effective 07/29/2026 was noted to include the non-measurable outcome statement for two problems; the first identified as “Comfort” and the second identified as “Pain”: “Pt will maintain comfort while on hospice.” The POC did not include a definition of comfort as defined by the patient and did not identify specific interventions that would be performed by the IDT for the patient to achieve patient-defined comfort. The POC included pain interventions but did not include the patient-appropriate measurable pain outcomes identified in the comprehensive assessment CLINICAL RECORD 7: The patient elected the hospice benefit on 06/04/2026 and died at an ALF on 07/04/2026. The patient’s primary and pertinent secondary diagnoses included senile degeneration of the brain, abnormal weight loss, hypertension, and a sacral wound that developed in the last few days of life. The hospice POC effective 07/29/2026 was noted to include the intervention statement, “Assess PO intake and encourage supplements”, and the following non-measurable outcome statement for the identified problem of Abnormal Weight Loss: “Patient will consume enough calories to maintain weight.” CLINICAL RECORD 8: The patient elected the hospice benefit on 06/20/2026 and died at home on 06/30/2026. The patient’s primary and pertinent secondary diagnoses included protein-calorie malnutrition, hypertensive heart disease with heart failure, dysphagia, dementia, encounter for fitting and adjustment of a urinary device (Foley Catheter), atrial fibrillation, quadriplegia, and Alzheimer’s disease. The hospice POC effective 06/20/2026 was noted to include the non-measurable outcome statement for two problems; the first identified as “Comfort” and the second identified as “Pain”: “Pt will maintain comfort while on hospice.” The POC did not include a definition of comfort as defined by the patient and did not identify specific interventions that would be performed by the IDT for the patient to achieve patient-defined comfort. The POC included pain interventions but did not include the patient-appropriate measurable pain outcomes identified in the comprehensive assessment. CLINICAL RECORD 9: The patient elected the hospice benefit on 11/04/2025 and died at home on 03/25/2026. The patient’s primary and pertinent secondary diagnoses included senile degeneration of the brain, dementia, fractured femur, and bed confinement status. The hospice POC effective 02/02/2026 was noted to include the following non-measurable outcome for the problem identified as “Comfort”, originally identified on 11/04/2025: “Pt will maintain comfort while on hospice.” The POC did not include a definition of comfort as defined by the patient and did not identify specific interventions that would be performed by the IDT for the patient to achieve patient-defined comfort. CLINICAL RECORD 10: The patient elected the hospice benefit on 07/03/2026 and died at home on 07/22/2026. The patient’s primary and pertinent secondary diagnoses included Malignant neoplasm of the kidney with abdominal and pulmonary metastases, end-stage renal disease, and Type 2 diabetes mellitus with diabetic chronic kidney disease. The hospice POC effective 07/03/2026 was noted to include the non-measurable outcome statement for two problems; the first identified as “Comfort” and the second identified as “Pain”: “Pt will maintain comfort while on hospice.” The POC did not include a definition of comfort as defined by the patient and did not identify specific interventions that would be performed by the IDT for the patient to achieve patient-defined comfort. The POC included pain interventions but did not include the patient-appropriate measurable pain outcomes identified in the comprehensive assessment. CLINICAL RECORD 11: The patient elected the hospice benefit on 10/27/2025. The patient’s primary and pertinent secondary diagnoses included heart failure, chronic pain syndrome, atherosclerotic heart disease, and age-related physical debility. The hospice POC effective 08/23/2026 was noted to include the following non-measurable outcome for the problem identified as “Comfort”, originally identified on 10/27/2025: “Pt will maintain comfort while on hospice.” The POC did not include a definition of comfort as defined by the patient and did not identify specific interventions that would be performed by the IDT for the patient to achieve patient-defined comfort. An additional non-measurable outcome was written as “Dyspnea will be managed to the extent possible” and did not identify a patient-specific measurement that would signify management of dyspnea to patient-expressed satisfaction. CLINICAL RECORD 12: The patient elected the hospice benefit on 09/19/2025. The patient’s primary and pertinent secondary diagnoses included senile degeneration of the brain, major depressive disorder, and pressure injury wounds to the left foot and coccyx. The hospice POC effective 08/16/2026 was noted to include the following non-measurable outcome for the problem identified as “Comfort”, originally identified on 09/19/2025: “Pt will maintain comfort while on hospice.” The clinical record was reviewed and did not include a definition of comfort as defined by the patient and did not identify specific interventions that would be performed by the IDT for the patient to achieve patient-defined comfort. An additional non-measurable outcome was written as “Agitation will be managed to the extent possible” and did not identify a patient-specific measurement that would signify management of agitation to patient-observed satisfaction. CLINICAL RECORD 13: The patient elected the hospice benefit on 07/27/2026. The patient’s primary and pertinent secondary diagnoses included degenerative disease of the nervous system, vascular dementia, hypertension, hemiplegia and hemiparesis, and chronic obstructive pulmonary disease. The hospice POC effective 07/27/2026 was noted to include the following non-measurable outcome for the problem identified as “Comfort”: “Pt will maintain comfort while on hospice.” The POC did not include a definition of comfort as defined by the patient and did not identify specific interventions that would be performed by the IDT for the patient to achieve patient-defined comfort. CLINICAL RECORD 14: The patient elected the hospice benefit on 08/19/2026. The patient’s primary terminal diagnosis included senile degeneration of the brain. The hospice POC effective 08/19/2026 was noted to include the following non-measurable outcome for the problem identified as “Comfort”: “Pt will maintain comfort while on hospice.” The POC did not include a definition of comfort as defined by the patient and did not identify specific interventions that would be performed by the IDT for the patient to achieve patient-defined comfort. An additional non-measurable outcome was written as “Pain will be managed to the extent possible” and did not identify a patient-specific measurement that would signify management of pain. During a joint clinical record review and interview on 08/27/2026, the ARNP Clinical Manager agreed that the POCs were missing the above information.”

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure that each plan of care included treatments to meet the patient’s needs. CLINICAL RECORD 1: The patient elected the hospice benefit on 06/21/2026 and was discharged alive, no longer terminally ill, on 07/31/2026. The patient’s primary and pertinent secondary diagnoses included degenerative disease of the nervous system, encounter for fitting and adjustment of urinary device (suprapubic catheter), dysphagia, epilepsy, and stage 3 pressure ulcer of the sacral region. The patient resided in a board and care. The hospice plan of care (POC) effective 06/21/2026 included a wound care treatment order for the patient’s stage 3 sacral pressure ulcer, which was noted to be incomplete because it did not specify the frequency at which the wound care treatment should be performed or by whom: the board and care staff and/or the hospice nursing staff. During a joint clinical record review and interview on 08/27/2026, the ARNP Clinical Manager confirmed that wound care treatment orders for the patient’s stage 3 sacral pressure ulcer were written as follows on the POC effective 06/21/2026 in the medication list instructions for Santyl 250 Unit/GM: “Cleanse the ulcer with wound cleanser, pat dry, apply a nickel-thick amount of Santyl 250 Unit/GM, followed by saline moistened gauze, and cover with dry clean dressing. Apply to sacro-coccygeal area topically as needed for dislodged or soiled dressing.” The ARNP Clinical Manager acknowledged that the wound care treatment orders in the POC were incomplete. She stated, “The patient was in a Board and Care with staff that was doing the wound care before hospice services, and would continue after hospice discharged the patient. We [hospice nursing] would only do wound care if we were visiting and found it dislodged or soiled; otherwise, the Board and Care would continue doing the wound care. I understand that all wound care treatment orders should include how often the wound care should be performed and should specify who is responsible: the patient, caregiver, or hospice staff. I’ll make a note that we need to educate our hospice nurses and physicians to write orders that include frequency and who is responsible.” 418.56/L-536 Standard”

“It is required that written patient care instructions for a hospice aide are prepared by an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 8 of 11 (73%) clinical records that included hospice aide services, the organization did not ensure that all pertinent patient care instructions and safety precautions were included in the written instructions prepared for the hospice aide. CLINICAL RECORD 1: The patient elected the hospice benefit on 06/21/2026 and was discharged alive, no longer terminally ill, on 07/31/2026. The primary diagnosis and pertinent secondary diagnoses included degenerative disease of the nervous system, encounter for fitting and adjustment of urinary device (suprapubic catheter), dysphagia, epilepsy, and stage 3 pressure ulcer of the sacral region. The aide plan of care (POC), effective 06/21/2026, ordered aide visits five times weekly and did not include aspiration precautions that were included on the patient’s Hospice POC effective 06/21/2026. The aide POC also did not include special instructions or precautions related to the patient’s diagnoses of seizures, suprapubic catheter, or sacral wound. During a joint clinical record review and interview on 08/27/2026, the ARNP Clinical Manager confirmed that the aide POC effective 06/21/2026 did not include aspiration precautions, seizure precautions, instructions or precautions for the care or management of the suprapubic catheter, or management of the patient’s sacral wound dressings during the performance of personal care. The ARNP stated, “There is plenty of space to write specific instructions and special precautions on the aide plan of care. I understand that this is valuable information and required by regulation. I’ll instruct our nurses on the regulation.” CLINICAL RECORD 2: The patient elected the hospice benefit on 08/24/2024 and was discharged alive, no longer terminally ill, on 07/24/2026. The primary and pertinent secondary diagnoses included senile degeneration of the brain, metabolic encephalopathy, and a wound on the patient’s left lower leg. The aide plan of care (POC) effective 06/15/2026 ordered aide visits three times weekly and did not include aspiration precautions that were included on the patient’s Hospice POC effective 06/15/2026. The aide POC also did not include special instructions or precautions related to the patient’s left lower leg wound. During a joint clinical record review and interview on 08/27/2026, the ARNP Clinical Manager confirmed that the aide POC effective 06/15/2026 did not include aspiration precautions or management of the patient’s lower leg wound dressings during the performance of personal care. CLINICAL RECORD 7: The patient elected the hospice benefit on 06/04/2026 and died at an ALF on 07/04/2026. The patient’s primary and pertinent secondary diagnoses included senile degeneration of the brain, abnormal weight loss, hypertension, and a sacral wound that developed in the last few days of life. The aide POC, effective 06/04/2026, ordered aide visits four times weekly and was not updated after 7/1/2026, when the patient was noted by the aide to have developed a sacral wound. The aide POC did not include instructions on how to protect the patient’s wound dressings during the performance of personal care. During a joint clinical record review and interview on 08/27/2026, the ARNP Clinical Manager confirmed that the aide reported the new sacral wound to the RN. The RN documented the presence of the wound but as confirmed by the ARNP, did not update the aide’s POC instructions to include how to protect the sacral wound dressing during peri care. CLINICAL RECORD 8: The patient elected the hospice benefit on 06/20/2026 and died at home on 06/30/2026. The patient’s primary and pertinent secondary diagnoses included protein-calorie malnutrition, hypertensive heart disease with heart failure, dysphagia, dementia, encounter for fitting and adjustment of a urinary device (Foley Catheter), atrial fibrillation, quadriplegia, and Alzheimer’s disease. The aide POC effective 06/20/2026 ordered aide visits weekly and did not include aspiration precautions that were included on the patient’s Hospice POC effective 06/20/2026. During a joint clinical record review and interview on 08/27/2026, the ARNP Clinical Manager confirmed that the aide POC effective 06/20/2026 did not include aspiration precautions. CLINICAL RECORD 9: The patient elected the hospice benefit on 11/04/2025, and the patient died at home on 03/25/2026. The Primary and pertinent secondary diagnoses included senile degeneration of the brain, dementia, fractured femur, and bed confinement status. The aide POC, effective 02/02/2026, ordered aide visits three times weekly and was not updated after 02/24/2026, when the patient developed a mid-back pressure injury, to include instructions on how to protect the patient’s wound dressings during the performance of personal care. During a joint clinical record review and interview on 08/27/2026, the ARNP Clinical Manager confirmed that the Aide POC had not been updated after 02/24/2026 to include instructions for wound dressing management. CLINICAL RECORD 12: The patient elected the hospice benefit on 09/19/2025. The patient’s primary and pertinent secondary diagnoses included senile degeneration of the brain, major depressive disorder, and pressure injury wounds to the left foot and coccyx. The aide POC effective 07/16/2026 ordered aide visits five times weekly and did not include special instructions or precautions related to the patient’s left foot and coccyx wounds. During a joint clinical record review and interview on 08/27/2026, the ARNP Clinical Manager confirmed that the aide POC effective 07/16/2026 did not include instructions for the management of the patient’s left foot or coccyx wound dressings during the performance of personal care. CLINICAL RECORD 13: The patient elected the hospice benefit on 07/27/2026, effective through 10/24/2026, with primary and pertinent secondary diagnoses that included degenerative disease of the nervous system, vascular dementia, hypertension, hemiplegia and hemiparesis, and chronic obstructive pulmonary disease. The aide POC effective 07/27/2026 was reviewed and noted to be missing instructions for the type of bath that the patient was to receive at each aide visit. During a joint clinical record review and interview on 08/27/2026, the ARNP Clinical Manager confirmed that the aide POC effective 07/27/2026 did not specify the type of bath that the patient was to receive. The ARNP stated, “I know that the aides communicate with the RNs on our HIPAA-secure messaging platform about the patients. Both the aides and the RNs forget to write notes in the patient records sometimes. The RN is new, and I believe she forgot to update the aide’s plan of care to include the patient’s shower. Everything else that the aide is doing and other important instructions are included on the plan of care; I just think that the RN forgot to update the shower. I’ll make sure it gets updated.” CLINICAL RECORD 14: The patient elected the hospice benefit on 08/19/2026, effective through 11/16/2026, with a primary terminal diagnosis of senile degeneration of the brain. The aide POC effective 08/19/2026 ordered aide visits three times weekly and did not include aspiration precautions that were included on the patient’s Hospice POC effective 08/19/2026. During a joint clinical record review and interview on 08/27/2026, the ARNP Clinical Manager confirmed that the aide POC effective 08/19/2026 did not include aspiration precautions.”

“It is required that a patient’s clinical record includes, at a minimum, physician orders. This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) clinical records reviewed, the organization did not ensure that each patient’s record included physicians’ orders for all treatments provided during the hospice-elected benefit period(s). CLINICAL RECORD 1: The patient elected the hospice benefit on 06/21/2026 and was discharged alive, no longer terminally ill, on 07/31/2026. The patient’s primary and pertinent secondary diagnoses included degenerative disease of the nervous system, encounter for fitting and adjustment of urinary device (suprapubic catheter), dysphagia, epilepsy, and stage 3 pressure ulcer of the sacral region. The patient resided in a board and care. The hospice POC effective 06/21/2026 was noted to include a physician’s order for triple antibiotic ointment to be applied topically around the entry site of the suprapubic catheter as needed for redness. The POC did not contain any physician’s orders for the management of the suprapubic catheter. During a joint clinical record review and interview on 08/27/2026, the ARNP Clinical Manager confirmed that the POC did not contain physician’s orders for the management of the suprapubic catheter except for a PRN order for triple antibiotic ointment for site redness. CLINICAL RECORD 2: The patient elected the hospice benefit on 08/24/2024, and the patient was discharged alive, no longer terminally ill, on 07/24/2026. The patient’s primary and pertinent secondary diagnoses included senile degeneration of the brain, metabolic encephalopathy, and a wound on the patient’s left lower leg. The plan of care (POC) effective 06/15/2026 ordered Skilled nursing visits three times weekly. The POC did not include wound care treatment orders for the left lower leg wound. During a joint clinical record review and interview on 08/27/2026, the ARNP Clinical Manager confirmed that all LVN visit notes indicated that “wound care was performed as ordered” and that biweekly RN comprehensive assessment notes indicated wound care performed as follows: “Leg wound cleansed with wound cleanser, patted dry, Medi honey to wound bed followed by calcium alginate, covered with ABD dressing and secured with tape.” The ARNP stated, “I reviewed all physician orders and LVN and RN visit notes in the benefit period leading up to the patient’s discharge, and I don’t see physician wound care treatment orders.” CLINICAL RECORD 7: The patient elected the hospice benefit on 06/04/2026 and died at an ALF on 07/04/2026. The patient’s primary and pertinent secondary diagnoses included senile degeneration of the brain, abnormal weight loss, hypertension, and a sacral wound that developed in the last few days of life. The hospice POC did not include an IDG update or interim physician’s orders for a sacral wound identified by the hospice aide during a visit on 07/01/2026. During a joint clinical record review and interview on 08/27/2026, the ARNP Clinical Manager confirmed that the aide reported the new sacral wound to the RN. The RN documented the presence of the wound, but as confirmed by the ARNP, the RN did not document a physician’s order for the cleansing or covering of the patient’s newly developed sacral wound. CLINICAL RECORD 9: The patient elected the hospice benefit on 11/04/2025, and the patient died at home on 03/25/2026. The patient’s primary and pertinent secondary diagnoses included senile degeneration of the brain, dementia, fractured femur, and bed confinement status. Skilled nursing visits were ordered and performed three times weekly. The clinical record was reviewed, and skilled nursing visits revealed the development of a pressure injury to the patient’s mid-back, discovered on 02/24/2026. The skilled nursing visit notes included the performance of wound care as follows: “Wound cleansed with wound cleanser, patted dry, Medi honey applied to the wound bed, and foam dressing applied.” The clinical record did not include the physician’s orders for the wound treatment provided to the patient’s mid-back pressure injury. During a joint clinical record review and interview on 08/27/2026, the ARNP Clinical Manager confirmed the development of the pressure injury and wound treatments performed by the skilled nurses. The ARNP stated, “I looked in the orders [section of the electronic clinical record] and the IDG POC updates for the physician’s orders and could not find a written wound care treatment order. Obviously, we need to get better at writing the physician’s orders we receive.””