Iowa River Hospice

“Based on observation and interview, the facility failed to provide separation of hazardous areas from other areas in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.3.2.1.2), 2012 Edition. This deficient practice affects approximately 2 residents, staff, and visitors in 1 of 4 smoke zones. This facility has a capacity of 6 and a census of 4. Findings include: Observation and interview on 07/02/24 at 12:42 p.m., revealed the facility failed to maintain the ceiling in the File Room of South Hall. This room contained an approximately 4 inch by 4 inch hole and a 12 inch by 12 inch hole in the monolithic ceiling. The 12 inch by 12 inch hole was covered with thin plexiglass. This was confirmed by the Administrator at the time of the survey process. Observation and interview on 07/02/24 at 12:46 p.m., revealed the facility failed to maintain the ceiling in the Server Room of South Hall. This room contained an approximately 18 inch by 18 inch hole in the monolithic ceiling. This was confirmed by the Administrator at the time of the survey process.”

“Based on record review and interview, the facility failed to maintain a commercial cooking suppression system in accordance with National Fire Protection Association (NFPA) Standard 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations (Section-11.2.1), 2011 Edition. This deficient practice affects approximately all residents, staff, and visitors of the facility . This facility has a capacity of 6 and a census of 4. Findings include: Record review and interview on 07/02/24 at 12:06 p.m., revealed the facility failed to have the Ansul Suppression System for the kitchen hood inspected on a timely semi-annual interval. The last documented inspection report provided was dated 07/10/23.The Administrator verified this observation at the time of the survey process.”

“Based on record review and interview, the facility failed to conduct biennial sensitivity testing of smoke detectors in accordance with National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code (Section-14.4.5.3.2), 2010 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 6 and a census of 4. Findings include: Record review and interview on 07/02/24 at 1:08 p.m., revealed the facility was unable to provide recent documentation that the smoke detectors had a sensitivity test to ensure they were operating within the sensitivity range set forth by the manufacture. The last documented sensitivity test was dated 05/31/22. The Administrator verified this observation at the time of the survey process.”

“Based on observation and interview, the facility failed to maintain sprinklers in accordance with National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler Systems (Section-6.2.7.2), 2010 Edition. This deficient practice affects approximately 2 residents, staff, and visitors in 1 of 4 smoke zones. This facility has a capacity of 6 and a census of 4. Findings include: Observation and interview on 07/02/24 at 12:47 p.m., revealed that the quick response sprinkler located in the Server Room South Hall was missing the escutcheon ring. The Administrator verified this observation at the time of the survey process.”

“Based on observation and interview, the facility failed to ensure that corridor doors have a means of keeping the doors closed within the door frame in order to resist the passage of smoke in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.3.6.3.5), 2012 Edition. This deficient practice affects approximately 2 residents, staff, and visitors in 1 of 4 smoke zones. This facility has a capacity of 6 and a census of 4. Findings include: Observation and interview on 07/02/24 at 1:00 p.m., revealed the corridor door to Resident Room Cherry Suite failed to positively latch within the door frame in order to keep thedoor closed. The Administrator verified this observation at the time of the survey process.”

“Based on record review and interview, the facility is not conducting fire drills at least quarterly on each shift in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.7.1.6), 2012 Edition. This deficient practice affects all residents, staff, and visitors as the lack of drills can affect the abilities of staff to respond in the event of an actual emergency. This facility has a capacity of 6 and a census of 4. Findings include: Record review and interview on 07/02/24 at 11:50 a.m., revealed the facility was unable to provide fire drill documentation for a second shift drill for the 2nd quarter of 2024. Both drills were documented as occurring on the first shift. The Administrator verified these observations at the time of the survey process.”

“Based on hospice staff interview, clinical record review, and hospice policy review, the hospice agency failed to complete an initial comprehensive assessment within 48 hours after the patients election of the hospice benefit for 3 of 6 patients with wounds identified (Patients #7, #12, and #19). Failure for a hospice registered nurse (RN) to complete an initial comprehensive assessment within 48 after the election of hospice care benefit increased the risk that patient needs would not be identified and/or addressed appropriately and the hospice would have an incomplete base assessment for comparison in order to determine effectiveness of treatments and interventions. Findings include: 3. Patient #19 had a hospice admission date of 10/20/23, a death date of 10/27/23 and received services while residing in a private home. Clinical record review revealed the following: a. Initial comprehensive assessment completed by a registered nurse, dated 10/20/23, included documentation of a surgical incision not measured. b. Skilled nurse visit note, dated 10/25/23, included documentation looked at incision, no signs of infection, surrounding skin intact, sutures clean, dry, no drainage but lacked wound measurements. The skilled nurse failed to complete a wound assessment including wound measurements with the initial comprehensive assessment. The Administrator and Clinical Manager received the above findings. 2.Patient #12 had a hospice admission date of 5/18/24 and received hospice services while residing in a private residence. Clinical record review revealed the following: a. The initial and comprehensive assessment completed by Staff I, RN, included documentation of an open wound on the left posterior leg not measured. b. The skilled nurse visit notes, dated 5/19/24 and 5/20/24, lacked documentation of a wound assessment. The skilled nurse failed to complete a wound assessment, including wound measurements with the initial comprehensive assessment. According to the hospice policy, titled Wound Assessment dated June 2024, in pertinent part, Goal of palliative wound treatment: to focus on patient comfort, prevention of infection and progression of wound. Functional ability of the patient will be maintained. Assess skin and wound upon admission and at a minimum every 15 days, documentation should be specific for each wound site. Assess and document location, stage, size, pain, odor, drainage and appearance of wound and surrounding skin. Assess signs and symptoms of infection. Contact physician/healthcare provider for wound care orders. Document specific treatment to each wound. Provide education to the patient and/or caretaker. According to the hospice policy, titled Comprehensive Assessment - Initial dated June 2024, in pertinent part, the RN completes the initial assessment and ensures that orders for treatment and services are obtained to meet the immediate care and suport needs of the patient. In an interview on 6/18/24 at 2:36 PM, the Clinical Manager reported that wounds are assessed weekly. Patient #7 had a start of care date of 5/13/24 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: The Plan of Care (POC) dated 5/13/24 to 8/10/24 included orders for skilled nursing visits and to assess the wound at every nursing visit. The hospice admission visit on 5/13/24 performed by Staff F, Registered Nurse (RN) identified that the patient had a stage 2 pressure ulcer to her coccyx. The visit failed to include an assessment of the pressure ulcer. The interdisciplinary team (IDT) note on 5/21/24 did not update the comprehensive wound assessment for the stage 2 pressure ulcer to the coccyx and to assess the wound at every nursing visit. The IDT note on 6/4/24 identified that the stage 2 pressure ulcer to the coccyx healed on 6/3/24 and to assess the wound at every nursing visit. The stage 2 pressure ulcer to the coccyx was not assessed at the skilled nursing visits performed by Staff J, Registered Nurse (RN), on 5/17/24, 5/24/24, 5/31/24, 6/3/24, 6/7/24, 6/10/24, 6/14/24, 6/17/24. The hospice failed to assess the patients stage 2 pressure ulcer at admission and follow POC to assess the pressure ulcer at every skilled nursing visit”

“Based on hospice clinical record and hospice policy, the hospice failed to ensure all members of the hospice interdisciplinary team (IDT) completed a comprehensive assessment within 5 days after the patients election of the hospice benefit for 3 of 21 patients (Patients #2, #13, and #15). Failure of all members of the IDT to complete a comprehensive assessment of the patients condition increased the risk in the delay of identification and meeting of all the patient needs. Findings include: 3. Patient #2 had a hospice admission date of 2/15/24 and received hospice services while residing in a nursing home. Clinical record review revealed the following: a. The initial comprehensive assessment completed by a registered nurse (RN), dated 2/15/24, included an electronic signature, dated as completed on 2/28/24, 13 days after the visit date, 8 days late. b. The initial social work assessment completed by a social worker, dated 2/16/24, included an electronic signature, dated as completed on 2/16/24. c. The initial spiritual assessment completed by a chaplain, dated 2/21/24, included an electronic signature, dated as completed on 2/21/24, 6 days after the start of care date, 1 day late. The interdisciplinary group failed to complete the comprehensive assessment no later than 5 days after the start of care date. The Administrator and Clinical Manager received the above findings. According to the hospice policy titled, Comprehensive Assessment - Initial dated June 2024, in pertinent part, based on the patients needs and findings from the initial assessment, the registered nurse (RN) coordinates and designates disciplines that must participate in the comprehensive assessment of the patient within 5 days of the patients election of hospice care. Patient #13 had a hospice admission date of 4/12/24 and received hospice services while residing in a private home. Clinical record review revealed the following: They want assistance with daily cares, Chaplain, Nursing and Social worker. The Plan of Care (POC) dated 4/12/24 to 7/10/24 included orders for chaplain visits. The IDT note on 4/23/24 did not include documentation about the lack of the chaplains comprehensive assessment. The hospice failed to ensure all requested disciplines obtain comprehensive assessments within 5 days after the patients election of hospice care. Patient #15 had a hospice admission date of 3/19/24 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: The POC dated 3/19/24 to 5/18/24 included orders for skilled nursing social worker, and aide visits. The admission skilled nursing visit performed by Staff , RN on 3/19/24 included documentation that the assessment question do you want me to call a chaplain was answered yes. The hospice chaplain admission visit was performed by Staff S, Chaplain, on 4/23/24. The hospice failed to ensure all requested disciplines obtain comprehensive assessments within 5 after the patients election of hospice care.”

“Based on hospice staff interview, hospice clinical record review, and hospice policy review, the hospice failed to ensure the hospice registered nurse (RN) updated the comprehensive assessment to include wound assessment for 3 of 6 patients with wounds (Patients #7, #12, and #13). Failure to update the wound assessment increased the risk that patient needs would not be identified and/or addressed appropriately and the hospice would have an incomplete assessment in order to determine effectiveness of wound treatments and interventions. Findings include: 3.Patient #12 had a hospice admission date of 5/18/24 and received hospice services while residing in a private residence. Clinical record review revealed the following: a. The comprehensive assessment completed by Staff M, RN, dated 5/29/24, included documentation of a wound to the coccyx not measured. Staff M noted it would be assessed at the next visit. b. The comprehensive assessment completed by Staff M, dated 5/29/24, included documentation of a wound to the left lower lateral leg measuring 10 centimeters (cm) by 3.75 cm with a mild amount of serous drainage. The assessment failed to include wound depth. c. The skilled nurse visit note, dated 5/30/24, lacked a skin assessment or wound measurements for the coccyx wound. d. The Interdisciplinary Group (IDG) note on 6/11/24 identified wound care orders for the wound to the left lower lateral leg and the coccyx but lacked a description and measurements of the wounds. The hospice failed to update the comprehensive assessment to reflect the patient’s wounds on the left lower lateral leg and coccyx. The Administrator and Clinical Manager received the above findings. According to hospice policy titled, Comprehensive Assessment - Content dated June 2020, in pertinent part, the comprehensive assessment identifies the physical, psychosocial, emotional and spiritual needs of the patient related to the terminal illness that must be addressed in order to promote the patient’s well-being, comfort, and dignity throughout the dying process. Each assessment tool is designed to obtain information related to the patient’s history, current status, problems, and needs and contain data elements for the collection of information related to patient outcomes. The Interdisciplinary Team (IDT) uses information obtained from the comprehensive assessment tools to develop an effective plan of care with interventions that address the identified needs of the patient/family. In an interview on 6/18/24 at 2:36 PM, when asked what data elements are part of a comprehensive assessment, the Clinical Manager reported that hospice staff ask the core questions and will be triggered by the answers if a care plan is needed. The Clinical Manager reported that wounds are followed with QAPI (Quality Assurance and Performance Improvement). 1.Patient #7 had a start of care date of 5/13/24 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC) dated 5/13/24 to 8/10/24 included orders for skilled nursing visits and to assess the wound at every nursing visit. b.The hospice admission visit on 5/13/24 performed by Staff F, Registered Nurse (RN) identified that the patient had a stage 2 pressure ulcer to her coccyx. The visit failed to include an assessment of the pressure ulcer. c.The interdisciplinary team (IDT) note on 5/21/24 did not update the comprehensive wound assessment for the stage 2 pressure ulcer to the coccyx and to assess the wound at every nursing visit. d. The IDT note on 6/4/24 identified that the stage 2 pressure ulcer to the coccyx healed on 6/3/24 and to assess the wound at every nursing visit. e. The stage 2 pressure ulcer to the coccyx was not assessed at the skilled nursing visits performed by Staff J, Registered Nurse (RN), on 5/17/24, 5/24/24, 5/31/24, 6/3/24, 6/7/24, 6/10/24, 6/14/24, 6/17/24. The hospice failed to assess the patients stage 2 pressure ulcer at admission and update the comprehensive assessment to include the pressure ulcer. 2. Patient #13 had a hospice admission date of 4/12/24 and received hospice services while residing in a private home. Review of the clinical record revealed the following: a. The POC dated 4/12/24 to 7/10/24 included orders for skilled nursing visits. b. The skilled nursing visit on 5/13/24 performed by Staff J, RN included documentation that the patient had a skin tear. c. The IDT note on 5/21/24 did not include documentation of the patients skin tear including assessment or treatment orders. The hospice failed to update the comprehensive assessment for the patients skin tear.”

“Based on clinical record review, hospice policy review, and staff interviews, the hospice failed to ensure the drug regimen review identified, at a minimum, the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with lab monitoring for 3 of 21 sampled patients (Patients #8, #9 and #14). Failure to ensure the interdisciplinary group (IDG) members involved in the assessment of patient needs identified all components of the drug regimen review (DRR) with each update to the comprehensive assessment increased the risk of of unidentified side effects and actual interactions of medications. Findings include: 2. Patient #9 had a hospice admission date of 5/16/24 and received hospice services while residing in a private home. Review of the clinical record revealed the following: a. The plan of care (POC), dated 5/16/2024 To 8/13/2024, included physicians orders for the following medications: Albuterol (respiratory inhaler), Atropine (used to control secretions), Morphine (pain), Viagra (erectile dysfunction) Tamsulosin (prostrate), and Lorazepam (anxiety). b. The Pharmacist completed a drug regimen review (DRR), dated 5/28/24, that include duplicate drug therapy, drug side effects, and actual or potential interactions. The hospice failed to ensure the DRR identified drug therapy associated with lab monitoring and effectiveness of drug therapy. 3. Patient #14 had a hospice admission date of 4/27/24, and received hospice services while residing in an assisted living facility. Review of the clinical record revealed the following: a. The plan of care (POC), dated 4/27/2024 to 7/25/2024, included physicians orders for the following medications: Tramadol (pain), Hydrocodone (pain), acetaminophen (pain), Lidocaine Patch (topical for pain), Fluticasone (nasal spray), Trazadone (depression/anxiety), Requip (muscle spasms) and Gabapentin ( nerve pain). b. The Pharmacist completed a drug regimen review (DRR), dated 6/6/24, that included drug side effects, and actual or potential interactions. The hospice failed to ensure the DRR identified duplicate drug therapy and drug therapy associated with lab monitoring and effectiveness of drug therapy. The Administrator and the Clinical manager received the above findings. According to the hospice policy, titled Comprehensive Assessment-Content, dated 6/2024, the comprehensive assessment of the patient consists of discipline specific assessment tools that address several things including a review of all the patient’s prescription and over the counter drugs, herbal remedies, and other alternative treatments that could affect drug therapy. According to the hospice policy, titled Medication Profile, dated 6/2024, a patient specific profile is maintained for each patient and reviewed, at a minimum, every fifteen days. The patient’s medication profile review includes, but is not limited to: monitoring medication effectiveness, actual or potential medication related effects, identifying duplicate drug therapy and drug therapy associated with laboratory monitoring, and untoward interactions. 1.Patient #8 had a hospice admission date of 5/20/24 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The plan of care (POC), dated 5/20/24 to 8/17/24 included physician orders for the following medications: diclofenac topical gel (pain relief), famotidine (antacid), furosemide (diuretic), sotalol (antiarrhythmic), dexamethasone (steroid), losartan (anti-hypertensive), polyethylene glycol (laxative), potassium chloride (electrolyte supplement), sertraline (antidepressant), trazadone (sedative), doxycycline (antibiotic), acetaminophen-oxycodone (pain relief), albuterol-ipratropium (dilates airways), ocular lubricant solution (moistens eyes), acetaminophen (pain/fever), bisacodyl suppository (constipation), lorazepam (anxiety/restlessness), and sodium chloride nasal spray (moistens inside of nose). b. The nursing facility completed a drug regimen review (DRR) that include duplicate drug therapy, drug side effects, and actual or potential interactions. The hospice failed to ensure the DRR identified drug therapy associated with lab monitoring and effectiveness of drug therapy.”

“Based on hospice staff interview, clinical record review, hospice policy review, the hospice failed to follow the individualized plan of care established in collaboration with the interdisciplinary group (IDG) including the patient or representative, and the primary caregiver in accordance with the patients needs if any of them desire for 7 of 21 patients (Patients #7, #8, #11, #13, #15, #20, and #21). Failure to follow the patient’s Plan of Care as directed by the Interdisciplinary Group( IDG) puts the patient at risk for inconsistent care that may not meet the needs of the patient. Findings include: 6. Patient #20 had a hospice admission date of 7/6/24, a death date of 7/21/24 and received hospice services while residing in a private home. Clinical record review revealed the following: a. The Plan of Care, dated 7/6/23 to 10/3/23, included orders for skilled nursing services 1-2 times per week, social work services 1-3 times per month and hospice aide services 3 times per week. b. Hospice aide visit notes, dated 7/10, 7/12, 7/13, 7/14, 7/17, 7/18, 7/19 and 7/20/23 included documentation of a completed visit. c. Hospice aide care plan, dated 7/6/23, included documentation on the bottom of the handwritten care plan extra visit 7/13/23 per family request. d. The IDG (interdisciplinary group) meeting note, dated 7/11/23, lacked documentation of physician orders to increase hospice aide visit frequency. e. The clinical record lacked documentation of a physician order for the additional hospice aide visit. The clinical record failed to identify an interim physician order or IDG documentation of massage therapy services. 7. Patient #2 had a hospice admission date of 2/15/24 and received hospice services while residing in a nursing home. Clinical record review revealed the following: a. The Plan of Care, dated 5/15/24 to 8/12/24, included orders for skilled nursing, social work, hospice aide, chaplain and volunteer services. b. Massage therapist note, dated 6/7/24, included documentation of a completed visit. c. IDG meeting note, dated 6/4/24, lacked documentation of massage therapy frequency or upcoming visit on 6/7/24. The clinical record failed to identify an interim physician order or IDG documentation of massage therapy services. The Administrator and Clinical Manager received the above findings. Review of the hospice policy, titled Interdisciplinary Team, dated January 2024, in pertinent part, included the interdisciplinary team (IDT) is responsible for: providing or coordinating care and services in accordance with the patients plan of care. A registered nurse (RN) member of the IDT is designated as the RN Case Manager for patient/family. The RN Case Manager is responsible for coordinating the care and services provided by the IDT, ensuring continuous assessment of the patient/family needs, and implementing the interdisciplinary plan of care. 2. Patient #11 had a hospice admission date of 5/28/24 and received hospice services while residing in an assisted living facility. Review of the clinical record revealed the following: The POC, dated 5/28/24 to 8/25/24, included physician orders for skilled nursing, aide, social worker, and chaplain. The IDT note on 6/4/24 included orders for skilled nursing, aide, social worker, and chaplain. The hospice admission visit was performed on 5/28/24 by Staff F, RN. During the visit, the patients wife requested music therapy for the patient. The hospice failed to provide music therapy for the patient. In an interview on 6/18/24 at 4:10 PM, the Clinical Manager reported that admissions are reviewed at the next days morning meeting. When disciplines are requested at admission, the process is started after this is reported at the morning meeting. 3. Patient #13 had a hospice admission date of 4/12/24 and received hospice services while residing in a private home. Clinical record review revealed the following: a. The POC, dated 4/12/24 to 7/10/24, included physician orders for skilled nursing services to assess patient’s pain each visit using the pain assessment in advanced dementia (PAINAD) scale. b. The skilled nurse visit notes, dated 4/23, 4/26, 4/29, 5/23, 6/6, 6/10, identified Staff J, RN completed the pain assessment utilizing the PAINAD scale. The documentation failed to show the completed PAINAD scale. 4. Patient #15 had a hospice admission date of 3/19/24 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The IDG notes on 4/23/24, 5/7/24, 5/21/24, and 6/4/24 directed nurses to assess pain at each visit - utilize the PAINAD scale. b. The skilled nurse visit note, dated 4/24 by Staff R, Licensed Practical Nurse (LPN), 5/23 by Staff J, RN, 6/11 by Staff J, identified the pain assessment was completed utilizing the PAINAD scale. The visit documentation failed to show the completed PAINAD scale. 5. Patient #21 had a hospice admission date of 2/2/24 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The chaplain visit note was dated 2/7/24. b. The POC dated 2/2/24 to 5/1/24 did not include orders for chaplain services. c. The hospice failed to obtain orders for chaplain services prior to the initial chaplain visit. Review of the policy, titled Plan of care, dated 6/2024, revealed each patient’s plan of care (POC) includes all services necessary for the palliation and management of the terminal illness and its related conditions. The plan includes, but is not limited to: interventions to manage pain and symptoms, a detailed scope and frequency of services necessary to meet the specific patient and family needs, measurable outcomes, and medical supplies, equipment and appliances necessary to meet the needs of the patient. 1.Patient #8 had a hospice admission date of 5/20/24 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The plan of care (POC), dated 5/20/24 to 8/17/24, included physician orders for skilled nursing services to assess patient’s pain each visit using the Face, Legs, Activity, Cry, Consolability (FLACC) scale. b. The skilled nurse visit note, dated 5/24/24, identified Staff G, Registered Nurse (RN) completed the pain assessment utilizing the FLACC scale. The documentation failed to show the completed FLACC scale. c. The skilled nurse visit note, dated 5/30/24, identified Staff H, RN completed the pain assessment utilizing the FLACC scale. The documentation failed to show the completed FLACC scale.”

“Based on home visit observations, patient interviews, clinical record reviews and agency policy reviews, the hospice failed to ensure Plans of Care (POC) for 9 of 21 sampled patients (Patients #2, #5, #7, #8, #11, #12, #13, #14 and #16) identified all medical equipment and supplies necessary to meet identified patient needs. Failure to include all needed items of medical equipment and supplies the patient used on the POC placed the patients at risk of unanticipated decline or injury and of needs not met. 9. Patient #2 had a hospice admission date of 2/15/24 and received hospice services while residing in a nursing home. Clinical record review revealed the following: a. The POC, dated 4/1/24 to 5/14/24 and 5/15/24 to 8/12/24, identified the patient used the following medical equipment and supplies: bedside table, hospital bed, shower chair, walker, wheelchair, hand held shower head, gait belt, hand splint. b. During a home observation visit on 6/19/24 at 3:35 PM with Staff E, RN (registered nurse), surveyor observed patient with bilateral leg braces on, Staff E verified pt was wearing leg braces and had them for awhile. c. The IDG meeting notes, dated 4/23/24, 5/7/24, 5/21/24 and 6/4/24, failed to include the leg braces as medical equipment used by the patient. The POC and IDG meeting notes failed to identify all necessary medical equipment and supplies used by the patient, including the leg braces. The Administrator and Clinical Manager received the above findings. 5. Patient #5 had a start of care date of 6/6/24 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 6/6/24 to 9/3/24, identified the patient had the following medical equipment and supplies: shower chair, walker, cane, and hand held shower head. b. The skilled nurse visit note performed by Staff G, Registered Nurse (RN), dated 6/6/24, identified the patient is incontinent. c. The Interdisciplinary Group (IDG) meeting notes, dated 6/11/24 identified no additional medical equipment and supplies used by the patient. The POC and IDG meeting to update the POC, failed to identify the additional DME of incontinent supplies used by the patient. 6. Patient #7 had a start of care date of 5/13/24 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 5/13/24 to 8/10/24, identified the patient had the following medical equipment and supplies: oxygen concentrator. The POC included an order for wound treatment with a padded adhesive dressing to coccyx changed every 3 days and prn (as needed). b. The admission skilled nurse visit note by Staff F, RN, dated 5/13/24, identified the patient is incontinent and wears incontinence pads. c. The skilled nurse visits performed by Staff J, RN, dated 5/20/24, 5/24/24, 5/28/24, 6/7/24, 6/10/24, 6/14/24 included that the patient wore incontinence briefs and that the order to change the padded adhesive dressing to coccyx was completed. d. The Interdisciplinary Group (IDG) meeting notes, dated 5/21/24 and 6/4/24 identified no additional medical equipment and supplies used by the patient. 7. Patient #11 had a hospice admission date of 5/28/24 and received hospice services while residing in an assisted living facility. Review of the clinical record revealed the following: a. The POC, dated 5/20/24 to 8/17/24, identified the patient had the following medical equipment and supplies: bedside table, oxygen concentrator, portable oxygen, shower chair, wheelchair, wheelchair cushion, hospital bed, and Sabina lift. b. The skilled nurse visit note, dated 6/6/24, identified the patient is incontinent and wears briefs. c. The Interdisciplinary Group (IDG) meeting notes, dated 6/11/24 identified no additional medical equipment and supplies used by the patient. The POC, and IDG meeting to update the POC, failed to identify the additional DME of incontinent supplies used by the patient. 8. Patient #13 had a hospice admission date of 4/12/24 and received hospice services while residing in a private home. Clinical record review revealed the following: a. The POC, dated 5/20/24 to 8/17/24, identified the patient had the following medical equipment and supplies: bedside table, oxygen concentrator, portable oxygen, shower chair, wheelchair, wheelchair cushion, hospital bed, and Sabina lift. b. The skilled nurse visit note, dated 6/6/24, identified the patient is incontinent and wears briefs. c. The Interdisciplinary Group (IDG) meeting notes, dated 6/11/24 identified no additional medical equipment and supplies used by the patient. The POC, and IDG meeting to update the POC, failed to identify the additional DME of incontinent supplies used by the patient. 3. Patient #14 had a start of care date of 4/27/24 and received hospice services while residing in an assisted living facility. Clinical record revealed the following: a. The POC (Plan of Care) dated, 4/27/2024 to 7/25/2024, identified the patient had the following medical equipment and supplies: shower chair, walker, wheelchair, hospital bed. b. Hospital discharge records, dated 4/26/24, indicated the patient had fallen and struck her head on a bedside table. c. The Interdisciplinary Group (IDG) meeting notes, dated 5/7/24, identified no additional medical equipment and supplies used by the patient. The POC, and IDG meeting to update the POC, failed to identify the additional DME of bedside table used by the patient. 4. Patient #16 had a start of care date of 3/27/24 and received hospice services in a private home. Review of the clinical record revealed the following: a. The POC, dated 4/1/2024 To: 6/24/2024 , identified the patient had the following medical equipment and supplies: shower chair, suction machine, walker, wheelchair, hand held shower head, incontinent supplies and a lift chair. b. The POC included a physician order effective 4/1/24 for Oxygen 2L per nasal cannula. c. The POC included a physician order for a foley catheter effective 4/1/2024. The Interdisciplinary Group (IDG) meeting notes, dated 4/9/24, identified no additional medical equipment and supplies used by the patient. The IDG updates to the plan of care failed to identify the additional DME of oxygen and foley catheter supplies used by the patient. Review of the hospice policy, titled Plan of Care, dated 6/2024, revealed each patient’s plan of care (POC) includes all services necessary for the palliation and management of the terminal illness and its related conditions. The plan includes, but is not limited to: interventions to manage pain and symptoms, a detailed scope and frequency of services necessary to meet the specific patient and family needs, measurable outcomes, and medical supplies, equipment and appliances necessary to meet the needs of the patient. 1.Patient #8 had a start of care date of 5/20/24 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 5/20/24 to 8/17/24, identified the patient had the following medical equipment and supplies: bedside table, oxygen concentrator, portable oxygen, shower chair, wheelchair, wheelchair cushion, hospital bed, and Sabina lift. b. The skilled nurse visit note, dated 6/6/24, identified the patient is incontinent and wears briefs. c. The Interdisciplinary Group (IDG) meeting notes, dated 6/11/24 identified no additional medical equipment and supplies used by the patient. The POC, and IDG meeting to update the POC, failed to identify the additional DME of incontinent supplies used by the patient. 2.Patient #12 had a hospice admission date of 5/18/24 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 5/18/24 to 8/15/24 did not identify any medical equipment and supplies utilized by the patient. b. The skilled nurse visit note, dated 5/18/24, identified the patient self-catheterizes up to 7 times a day. c. The social worker visit note, dated 5/20/24, identified the patient was wearing a life alert button. d. The IDG meeting note, dated 5/28/24 identified the following medical equipment and supplies utilized by the patient: oxygen concentrator, walker, grab bars. The POC, and IDG meeting to update the POC, failed to identify the DME of catheter supplies and life alert button.”

“Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the Interdisciplinary Group maintained a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care for 5 of 21 sampled patients (Patients #8, #10, #12, #14 and #18) with a missed visit. Failure of the hospice interdisciplinary group (IDG) members to maintain a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care increased the risk that patients did not receive services to meet assessed needs. Findings include: 5. Patient #18 had a hospice admission date of 2/23/24, a discharge date of 4/21/24 and received hospice services while residing in an assisted living facility. Clinical record review revealed the following: a. The interdisciplinary group (IDG) meeting note, dated 4/2/24, included IDG direction to provide volunteer services one time a week for 4 weeks. b. The week of 4/1/24 lacked documentation of a completed volunteer visit. c. The IDG meeting note, dated 4/16/24, lacked documentation the IDG was notified of a missed volunteer visit for the week of 4/1/24. The hospice failed to provide volunteer visits as ordered per the IDG updates to the Plan of Care. The Administrator and Clinical Manager received the above findings. 4. Patient #14 had a start of care date of 4/27/24 and received hospice services in an assisted living facility. Review of the clinical record revealed the following: a. The Interdisciplinary Group (IDG) meeting notes, dated 5/7/24, included orders for social worker visits to be one time a week for 12 weeks. b. The social worker visit notes, dated 5/7/24 and 5/15/24, were completed. c. The hospice failed to complete a social works visit for the weeks of 5/19/24 and 5/26/24. d. The IDG meeting notes, 5/21/24 and 6/4/2024, lacked documentation of any missed visits by social worker. According to the hospice policy titled Coordination of Services, dated 9/2023, the Interdisciplinary Group (IDG) ensures there is a coordinated and effective ongoing sharing of information amongst and between all disciplines. Any missed visits must be reported, discussed, and documented in the IDG note. During and interview on 6/19/24 at 2:07 PM, the Administrator reported the team discusses missed visits at IDG meetings and they will need to make sure this is reflected in the IDG notes. 1.Patient #8 had a start of care date of 5/20/24 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The Interdisciplinary Group (IDG) meeting notes, dated 5/28/24 to 6/11/24, included orders for social worker services one to three times a week and hospice aide services four times a week. b. The hospice aide visit notes, dated 5/21/24, 5/22/24, and 5/24/24 were completed. The hospice failed to complete a fourth aide visit the week of 5/20/24. c. The hospice failed to complete any social work visits the week of 5/26/24. d. The IDG meeting notes, dated 5/28/24 and 6/11/24, lacked documentation of any missed visits by social workers or hospice aides. 2.Patient #10 had a start of care date of 5/23/24 and received hospice services while residing in an assisted living facility. Clinical record review revealed the following: a. The IDG note, dated 6/4/24, included orders for hospice chaplain services one time per week. b. The hospice failed to complete a hospice chaplain visit the week of 5/26/24. c. The IDG meeting note, dated 6/4/24, lacked documentation of any missed visits by hospice chaplains. 3.Patient #12 had a hospice admission date of 5/18/24 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The IDG meeting notes, dated 5/28/24 and 6/11/24, included orders for skilled nursing visits one time a week for one week and three to five times a week for twelve weeks, hospice aide visits one time a week for one week and 5 times a week for twelve weeks, and social work visits three times a week. b. The hospice failed to complete a hospice aide visit the week of 5/18/24. c. The social worker visit note, dated 5/20/24 was completed. The hospice failed to complete three social works visits the weeks of 5/19/24, 5/26/24, 6/2/24, and 6/9/24. d. The skilled nurse visit notes, dated 5/19/24, 5/20/24, 5/23/24, 5/29/24, and 5/30/24 were completed. The hospice failed to complete a third skilled nurse visit the week of 5/26/24. e. The IDG meeting notes, dated 5/28/24 and 6/11/24 lacked documentation of any missed visits by skilled nurses, hospice aides, or social workers.”

“Based on staff interviews, clinical record reviews, and hospice policy review, the hospice failed to ensure hospice aides provided services as ordered by the Interdisciplinary Group (IDG) according to the individualized plan of care for 2 of 17 sampled patients who received hospice aide services (Patients #13 and #18 ). Failure to provide hospice aide services as ordered on the plan of care increased the risk that hospice patients’ personal care needs were not met. Findings include: 2. Patient #18 had a hospice admission date of 2/23/24, a discharge date of 4/21/24 and received hospice services while residing in an assisted living facility. Clinical record review revealed the following: a. The hospice aide care plan, dated 2/23/24, included a visit frequency of 5 times a week and Registered Nurse instructions to the hospice aide to perform the task trim and file fingernails 1 time per week. b. Hospice aide visit notes, dated 4/1, 4/5, 4/15 and 4/16/24, included documentation the task trim and file fingernails was completed. The hospice aide failed to provide services as instructed by the RN assignment. The Administrator and Clinical Manager received the above findings. According to the hospice policy titled Hospice Aide Supervision, dated June 2020, in pertinent part, hospice aides are supervised by a registered nurse (RN) in a manner and frequency that assures the safety of patients and the quality of aide services provided. The supervising RN assesses an aide’s ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that include, but are not limited to: following the patient’s plan of care for completion of assigned tasks. 1.Patient #13 had a hospice admission date of 4/12/24 and received hospice services while residing in a private home. Clinical record review revealed the following: a. The POC dated 4/12/24 to 7/10/24 included orders for aide services and the interventions for the aide to complete at each visit. b. The hospice aide visit on 4/15/24 included the narrative that patient allowed cares to be done. c. The hospice aide visit on 5/21/24 included the narrative that patient allowed cares to be done. d. The hospice aide visits failed to document which interventions were completed at each visit.”

“Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to document location of the annual on-site visit made by the Registered Nurse where a patient is receiving care in order to observe and assess each aide while performing care for 4 of 4 hospice aides (Staff N, O, P and Q) with annual supervision in 2023. Failure to ensure the hospice aides were supervised annually by the Registered Nurse, including location observed, increased the risk patient care needs may not be adequately met. Findings include: The hospice policy, titled Hospice Aide Supervision, dated 9/2023, included documentation a Registered Nurse makes an annual on-site visit to the location where a patient is receiving care to observe and assess each aide while they are performing care. During an interview on 6/20/24 at 10:25 AM, Clinical Manager reported the annual hospice aide supervision is completed in patient homes, facilities or at the hospice house. After reviewing the supervision/competency forms for the hospice aides the Clinical Manager agreed the location of the supervision was not identified. 1. Staff N, Hospice aide, had a hire date of 4/9/2003, and an annual supervision visit form, dated 11/16/23, that lacked location of the supervision. 2. Staff O, Hospice aide, had a hire date of 9/8/2014, and an annual supervision visit form, dated 11/20/23, that lacked location of the supervision. 3. Staff P, Hospice aide, had a hire date of 5/25/21, and an annual supervision visit form, dated 11/17/23, that lacked location of the supervision. 4. Staff Q, Hospice aide, had a hire date of 9/2/97, and an annual supervision visit form, dated 11/21/23, that lacked location of the supervision. The hospice failed to identify the location of hospice aide annual supervision visits. The Administrator and Clinical Manager received the above findings.”

“Based on clinical record review and hospice policy review, the hospice failed to document all required components of hospice aide supervision including following the patient plan of care, creating successful interpersonal relationships with the patient and family, demonstrating competency with assigned tasks, complying with infection control policies and procedures, and reporting changes in patient condition for 15 of 15 sampled patients (Patients #2, #3, #4, #6, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17 and #18) with hospice aide services. Failure to ensure the supervision of hospices by registered nurses maintained documentation of a review of all required supervisory elements increased the risk of agency staff not meeting the patients’ personal care needs. 11. Patient #2 had a hospice admission date of 2/15/24 and received hospice services while residing in a nursing home. Clinical record review revealed the following: a. The Plan of Care, dated 4/1/24 to 5/14/24 and 5/15/24 to 8/12/24, included orders for skilled nursing and hospice aide services. b. The skilled nurse visit notes, dated 4/16, 4/24, 5/3, 5/9, 5/17, 5/24, 6/7 and 6/12/24, included documentation the hospice nurse provided aide supervision. c. The supervision documentation failed to include the elements demonstrating competency with assigned tasks and complying with infection control policies and procedures. The hospice failed to document all required elements of hospice aide supervision. 12. Patient #3 had a hospice admission date of 3/10/23 and received hospice services while residing in a nursing home. Clinical record review revealed the following: a. The Plans of Care, dated 5/3/24 to 7/1/24, included orders for skilled nursing and hospice aide services. b. The skilled nurse visit notes, dated 5/3, 5/9, 5/16, 5/24, 5/30, 6/5 and 6/13/24, included documentation the hospice nurse provided aide supervision. c. The supervision documentation failed to include the elements demonstrating competency with assigned tasks and complying with infection control policies and procedures. The hospice failed to document all required elements of hospice aide supervision. 13. Patient #4 had a hospice admission date of 10/1/23 and received hospice services while residing in a nursing home. Clinical record review revealed the following: a. The Plan of Care, dated 5/28/24 to 7/26/24, included orders for skilled nursing and hospice aide services. b. The skilled nurse visit notes, dated 6/3 and 6/11/24, included documentation the hospice nurse provided aide supervision. c. The supervision documentation failed to include the elements demonstrating competency with assigned tasks and complying with infection control policies and procedures. The hospice failed to document all required elements of hospice aide supervision. 14. Patient #17 had a hospice admission date of 10/30/23, a discharge date of 5/10/24 and received hospice services while residing in a private home from 10/30/23 to 12/28/23, the hospice house from 12/29/23 to 4/9/24, and a nursing home from 4/10/24 to 5/10/24. Clinical record review revealed the following: a. The Plan of Care, dated 1/28/24 to 4/26/24, included orders for skilled nursing and hospice aide services. b. The skilled nurse visit notes, dated 4/16 and 4/30/24, included documentation the hospice nurse provided aide supervision. c. The supervision documentation failed to include the elements demonstrating competency with assigned tasks and complying with infection control policies and procedures. The hospice failed to document all required elements of hospice aide supervision. 15. Patient #18 had a hospice admission date of 2/23/24, a discharge date of 4/21/24 and received hospice services while residing in an assisted living facility. Clinical record review revealed the following: a. The Plan of Care, dated 2/23/24 to 4/22/24, included orders for skilled nursing and hospice aide services. b. The skilled nurse visit notes, dated 4/2, 4/9 and 4/18/24, included documentation the hospice nurse provided aide supervision. c. The supervision documentation failed to include the elements demonstrating competency with assigned tasks and complying with infection control policies and procedures. The hospice failed to document all required elements of hospice aide supervision. The Administrator and Clinical Manager received the above findings. 8. Patient #9 had a hospice admission date of 5/16/24 and received hospice services while residing in a private home. Clinical record review revealed the following: a. The Plan of Care, dated 5/16/24 to 8/13/24, included orders for skilled nursing and hospice aide services. b. The skilled nurse visit notes, dated 5/22/24, 5/29/24, and 6/12/24 included documentation the hospice nurse provided aide supervision. c. The supervision documentation failed to include the elements demonstrating competency with assigned tasks and complying with infection control policies and procedures. The hospice failed to document all required elements of hospice aide supervision. #9. Patient #14 had a hospice admission date of 4/27/24 and received hospice services while residing in an assisted living facility. Clinical record review revealed the following: a. The Plan of Care, dated 4/27/24 to 7/25/25, included orders for skilled nursing and hospice aide services. b. The skilled nurse visit notes, dated 5/8/24, 5/24/24, 6/3/24 and 6/11/24 included documentation the hospice nurse provided aide supervision. c. The supervision documentation failed to include the elements demonstrating competency with assigned tasks and complying with infection control policies and procedures. The hospice failed to document all required elements of hospice aide supervision. 10. Patient #16 had a hospice admission date of 3/27/24 and received hospice services while residing in a private home. Clinical record review revealed the following: a. The Plan of Care, dated 3/27/24 to 6/24/24, included orders for skilled nursing and hospice aide services. b. The skilled nurse visit notes, dated 5/1/24, 5/16/24, 5/22/24 and 6/5/24 included documentation the hospice nurse provided aide supervision. c. The supervision documentation failed to include the elements demonstrating competency with assigned tasks and complying with infection control policies and procedures. The hospice failed to document all required elements of hospice aide supervision. 5. Patient #11 had a hospice admission date of 5/28/24 and received hospice services while residing in an assisted living facility. Review of the clinical record revealed the following: a. The IDG meeting note, dated 6/4/24, included orders for skilled nursing and hospice aide services. b. The skilled nurse visit notes performed by Staff M, Registered Nurse (RN), dated 6/6/24, 6/12/24, and 6/12/24, included documentation the hospice nurse provided aide supervision. c. The supervision documentation failed to include demonstrating competency with assigned tasks and complying with infection control policies and procedures. The hospice failed to document all required components of hospice aide supervision. 6. Patient #13 had a hospice admission date of 4/12/24 and received hospice services while residing in a private home. Clinical record review revealed the following: a. The IDG meeting notes, dated 4/23/24, 5/7/24, and 5/21/24, 6/4/24, included orders for skilled nursing and hospice aide services. b. The skilled nurse visit notes, dated 4/19/24 by Staff M, 5/16/24 by Staff J RN, 5/20/24 by Staff J, 5/23/24 by Staff J, 6/3/24 by Staff J, 6/6/24 by Staff J, 6/10/24 by Staff J, 6/13/24 by Staff J included documentation the hospice nurse provided aide supervision. c. The supervision documentation failed to include demonstrating competency with assigned tasks and complying with infection control policies and procedures. The hospice failed to document all required components of hospice aide supervision. 7. Patient #15 had a hospice admission date of 3/19/24 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The IDG meeting notes, dated 4/23/24, 5/7/24 and 5/21/24, included orders for skilled nursing and hospice aide services. b. The skilled nurse visit notes, dated 4/15/24 by Staff J, 4/29/24 by Staff J, 5/6/24 by Staff J, 5/14/24 by Staff J, 5/23/24 by Staff J, 5/29/24 by Staff J, 6/3/24 by Staff J, and 6/11/24 by Staff J included documentation the hospice nurse provided aide supervision. c. The supervision documentation failed to include demonstrating competency with assigned tasks and complying with infection control policies and procedures. The hospice failed to document all required components of hospice aide supervision. Review of the hospice policy, titled Hospice Aide Supervision, dated 9/2023, identified the supervising registered nurse (RN), assesses an aide’s ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that include, but are not limited to: following the patient’s plan of care for completion of assigned tasks; creating successful interpersonal relationships with the patient and family; demonstrating competency with assigned tasks; complying with infection control practices; and reporting changes in the patient’s condition. The supervisory notes are documented in the patient’s clinical record every two weeks. 1.Patient #6 had a hospice admission date of 6/1/24 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The Interdisciplinary Group (IDG) meeting note, dated 6/11/24, included orders for skilled nursing and hospice aide services. b. The skilled nurse visit note, dated 6/12/24, included documentation the hospice nurse provided aide supervision. c. The supervision documentation failed to include demonstrating competency with assigned tasks and complying with infection control policies and procedures. The hospice failed to document all required components of hospice aide supervision. 2.Patient #8 had a hospice admission date of 5/20/24 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The IDG meeting notes, dated 5/28/24 and 6/11/24, included orders for skilled nursing and hospice aide services. b. The skilled nurse visit notes, dated 5/30/24, 6/6/24, and 6/13/24, included documentation the hospice nurse provided aide supervision. c. The supervision documentation failed to include demonstrating competency with assigned tasks and complying with infection control policies and procedures. The hospice failed to document all required components of hospice aide supervision. 3.Patient #10 had a hospice admission date of 5/23/24 and received hospice services while residing in an assisted living facility. Review of the clinical record revealed the following: a. The IDG meeting note, dated 6/4/24, included orders for skilled nursing and hospice aide services. b. The skilled nurse visit notes, dated 5/24/24, 6/6/24, and 6/10/24, included documentation the hospice nurse provided aide supervision. c. The supervision documentation failed to include demonstrating competency with assigned tasks and complying with infection control policies and procedures. The hospice failed to document all required components of hospice aide supervision. 4.Patient #12 had a hospice admission date of 5/18/24 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The IDG meeting notes, dated 5/28/24 and 6/11/24, included orders for skilled nursing and hospice aide services. b. The skilled nurse visit notes, dated 5/23/24, 6/6/24, and 6/12/24, included documentation the hospice nurse provided aide supervision. c. The supervision documentation failed to include demonstrating competency with assigned tasks and complying with infection control policies and procedures. The hospice failed to document all required components of hospice aide supervision.”

“Based on clinical record review, hospice policy review, and staff interview, the hospice failed to ensure all required components of physician certification of the patient’s terminal illness (CTI) for 2 of 21 sampled patients (Patients #8 and #13). Failure to obtain the physician’s certification of terminal illness puts the patient at risk of receiving hospice care inappropriately and/or without a funding source. Findings include: The Administrator and Clinical Manager received the above findings. 2. Patient #13 had a hospice admission date of 4/12/24 and received hospice services while residing in a private home. Clinical record review revealed the following: a. The Election of Hospice Care form signed by the patient for services to begin on 4/12/24 included the name of the patient’s attending physician chosen by the patient to oversee the patient’s care. b. The CTI for benefit period 1 from 4/12/24 to 7/10/24 included the hospice medical director’s electronic signature. c. The CTI for benefit period 1 from 4/12/24 to 7/10/24 failed to include the patient’s attending physician’s signature. Review of the hospice policy titled Certification of Terminal Illness, dated 1/2024, identified when a patient is first admitted to the hospice agency, the Medical Director or physician member of the Interdisciplinary Group (IDG) and the patient’s attending physician (if the patient has one) sign a written statement certifying the patient’s prognosis is 6 months or less if the terminal illness follows its normal course. 1.Patient #8 had a hospice admission date of 5/20/24 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Election of Hospice Care form signed by the patient for services to begin on 5/20/24 included the name of the patient’s attending physician chosen by the patient to oversee the patient’s care. b. The CTI for benefit period 1 from 5/20/24 to 8/17/24 included the medical director’s electronic signature. c. The CTI for benefit period 1 from 5/20/24 to 8/17/24 failed to include the patient’s attending physician’s signature. During an interview on 6/19/24 at 2:05 PM, the Administrator reported the agency can’t have the patient’s primary care physician sign anything because he/she hasn’t completed the Provider Enrollment, Chain and Ownership System for Medicare and the agency would be unable to bill for services. The hospice failed to have the medical director and the patient’s attending physician sign the initial certification of terminal illness for the patient.”

“Based on clinical record review, hospice policy review, and staff interviews, the hospice failed to ensure all documentation was included in the clinical record in a timely manner for 3 of 21 sampled patients (Patients #3, #8 and #12). Failure to ensure all clinical record documentation, and each patient’s clinical record was complete, timely, and appropriately authenticated, decreased the ability of hospice staff to communicate and coordinate patient care effectively, and to provide safe, effective hospice services to patients. Findings include: 3. Patient #3 had a hospice admission date of 3/10/23 and received hospice services while residing in a nursing home. Clinical record review revealed the skilled nurse visit note, dated 6/13/24, signed completed on 6/18/24, 5 days after the visit date, 2 days late. The hospice clinical record failed to include timely documentation. The Administrator and Clinical Manager received the above findings. Review of the hospice policy titled Clinical Records, dated 6/2024, identified all documentation must be completed in 72 hours of the service. If unforeseen circumstances occur, documentation can be extended per management approval. The initial assessment must be completed within 48 hours of the patient electing benefits. The comprehensive assessment components must be completed within 5 days of admission. During an interview on 6/18/24 at 2:36 PM, the Clinical Manager identified the expectation is documentation of visits is completed within 72 hours. The initial comprehensive assessment has to be completed within 5 days of the election of hospice services. 1.Patient #8 had a hospice admission date of 5/20/24 and received hospice services while residing in a nursing home. Clinical record review revealed the following: a. The skilled nurse visit note, dated 5/24/24, signed completed on 5/28/24 (1 day late). b. The skilled nurse visit note, dated 6/13/24, signed completed on 6/17/24 (1 day late). The hospice clinical record failed to include timely documentation. 2.Patient #12 had a hospice admission date of 5/18/24 and received hospice services while residing in a private residence. Clinical record review revealed the following: a. The skilled nurse visit note, dated 5/19/24, signed completed on 5/28/24 (6 days late). b. The skilled nurse visit note, dated 5/20/24, signed completed on 5/29/24 (6 days late). c. The skilled nurse visit note, dated 5/30/24, signed completed on 6/10/24 ( 8 days late). The hospice clinical record failed to include timely documentation.”

“Based on clinical record review and staff interview, the hospice failed to ensure the hospice staff provided protection of patient information for 1 of 1 sampled patients (Patient #2). Failure to ensure the hospice staff protected patient health information placed the patient at risk for not having a secured medical record. Findings: Patient #2 had a hospice admission date of 2/15/24 and received services while residing in a nursing home. Review of the clinical record included scanned documentation from the interdisciplinary group (IDG) meeting notes, dated 5/7/24, 5/21/24 and 6/4/24, included the list of patients discussed during the IDG meeting, the list of staff who attended the IDG meeting and documentation of a drug regimen review for the patient. The clinical record included documentation of multiple patient names on one patients clinical record. During an interview on 6/25/24 at 10:00 AM, Clinical Manager reported scanning the IDG patient list, staff attendance list and drug regimen review, into every patient clinical record for IDG meetings beginning April 2024. IDG meeting notes, dated 4/16/24, 4/23/24, 4/30/24, 5/7/24, 5/14/24, 5/21/24, 5/28/24, 6/4/24 and 6/11/24, were scanned into multiple patient records. The Administrator and Clinical Manager received the above findings.”

“Based on clinical record review and hospice policy review, the hospice failed to maintain documentation in the patient clinical records as evidence patients received a copy of the hospice policy concerning the disposal of controlled medications and hospice staff discussed this policy with the patient/caregiver for 4 of 9 sampled patients who received routine home care while living in a private residence or assisted living facility and had orders for controlled medications (Patients #10, #13, #14, and #18). Failure to ensure patients and/or caregivers received adequate education on the use and disposal of controlled substances increased the risk of inappropriate use of narcotics and other controlled substances by individuals other than the patient for whom the medication was prescribed. Findings include: 4. Patient #18 had a hospice admission date of 2/23/24, a discharge date of 4/21/24 and received hospice services while residing in an assisted living facility. Clinical record review revealed the following: a. A Plan of Care, dated 2/23/24, identified the following controlled medications: Lorazepam and Morphine Sulfate, with a start date of 2/23/24. b. A skilled nursing visit note, dated 2/23/24, lacked documentation of the lorazepam and morphine sulfate being initiated and lacked documentation the nurse provided written and verbal instruction on the hospice’s controlled drug policy. The Administrator and Clinical Manager received the above findings. 3. Patient #13 had a hospice admission date of 4/12/24 and received hospice services while residing in a private home. Clinical record review revealed the following: a. The initial POC, dated 4/12/24 to 7/10/24, included physician orders for medications, but no controlled medications. b. A skilled nurse visit note, dated 5/2/24, completed by Staff J, RN, identified lorazepam was started. c. An IDG meeting note, dated 5/7/24, included physician orders for lorazepam, a controlled medication, with a start date of 5/2/24. d. The clinical record lacked documentation that hospice staff reviewed the policy for the disposal of controlled medications at the time when the physician first ordered the controlled medications. 2. Patient #14 had a hospice admission date of 4/27/2024, and received hospice services while residing in an assisted living facility. Clinical record review revealed the following: a. The initial POC, dated 4/27/2024 to 7/25/2024, included physician orders for medications and included orders for a controlled substance; Hydrocodone (Pain Medication). b. The medication profile, dated 4/27/24, included Hydrocodone, a controlled medication, at the start of care. c. An IDG meeting note, dated 5/7/24, included physician orders for Hydrocodone, controlled medication effective from the start of care. d. The clinical record lacked documentation hospice staff reviewed the policy for the disposal of controlled medications at start of care. Review of the hospice policy titled Medications-Use and Disposal of Controlled Substances, dated 6/2024, identified at the time when controlled substances are first ordered, the hospice nurse provides a written copy of the policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family, the nurse discusses the policies and procedures on the management and disposal of controlled drugs, and documents in the patient’s clinical record the written policies and procedures were provided and discussed. 1.Patient #10 had a hospice admission date of 5/23/24 and received hospice services while residing in an assisted living facility. Clinical record review revealed the following: a. The initial plan of care (POC), dated 5/23/24 to 8/20/24, included physician orders for medications, but no controlled medications. b. A skilled nurse visit note, dated 6/2/24, completed by Staff L, Registered Nurse (RN), identified Lorazepam and Morphine Sulfate were started. c. An Interdisciplinary Group (IDG) meeting note, dated 6/4/24, included physician orders for Lorazepam and Morphine Sulfate; controlled medications. d. The clinical record lacked documentation hospice staff reviewed the policy for the disposal of controlled medications at the time when the physician first ordered the controlled medications per federal regulation.”

“Based on clinical record review and hospice staff interview, the hospice failed to ensure the nursing home received orientation and training of nursing home staff furnishing care to hospice patients in the hospice philosophy, including hospice policies and procedures. Failure to ensure the hospice staff provided the required orientation and training to nursing home staff placed the patient at risk for receiving inadequate care and/or treatments needed to meet the individual needs of the patient. Findings include: During an interview on 6/18/24 at 2:23 PM, Administrator reported the hospice has not provided any training to any nursing home staff on the hospice philosophy and has not offered inservices for hospice training to any nursing homes.”