Care Initiatives Hospice - Greenfield

“Based on review of emergency preparedness training rosters, review of the emergency preparedness plan and policies and staff interview, the hospice failed to ensure training inemergency preparedness for 1 of 1 contracted staff consistent with their expected roles for the calendar years of 2023 and 2024. Lack of emergency preparedness training for staff puts patients at risk should an emergency situation arise and staff would be needed to assist patients to ensure patient safety. During an interview on 10/15/25 at 8:50 AM, Staff J, Quality & Education Coordinator gave the surveyor the most current emergency preparedness training documentation for contracted Staff K, massage therapist. The Emergency preparedness training was dated 11/19/21. The agency failed to provide emergency preparedness training to their contracted staff every 2 years. The above findings were reviewed with the Vice President of Clinical Services, Administrator and Clinical Manager.”

“Based on staff interview, clinical record review and hospice policy review, the hospice failed to ensure hospice nurse members of the Interdisciplinary Group completed a complete and accurate comprehensive assessment at the time of hospice admission for 1 of 19 sampled patients. (Patient #1) Failure by the hospice Interdisciplinary Group (IDG) registered nurses to provide a complete and accurate comprehensive assessment at the time of hospice admission placed the patient at risk for ineffective staff collaboration and communication regarding patient’s effectiveness of treatments and interventions. Findings include: According to the hospice policy, titled Comprehensive Assessment, last revised 7/19/23, the hospice interdisciplinary group (IDG) conducts and documents a patient-specific comprehensive assessment that identifies the patient’s and caregiver’s needs for hospice care, including medical, nursing, psychosocial, emotional, and spiritual care. This assessment includes all areas of hospice care related to palliation and management of terminal illness and related conditions. Patient #1 had a hospice admission date of 9/22/25, and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care, dated 9/22/25 to 11/20/25, included primary diagnosis of senile degeneration of the brain and physician orders for skilled nursing services. b. The comprehensive skilled nurse note at the time of admission, dated 9/22/25, included documentation the patient had a tracheostomy and urinary catheter. c. During a home observation visit on 10/7/25 at 11:45 AM with Staff D, Registered Nurse (RN) the surveyor observed no evidence of a tracheostomy or urinary catheter. The hospice failed to complete an accurate comprehensive assessment at the time of admission. During an interview on 10/14/25 at 3:30 PM, Staff C, VP (Vice President) of Clinical Services, reported the chart was reviewed and she agreed the comprehensive assessment included the inaccurate information. The above findings were reviewed with the VP of Clinical Services, Administrator and Clinical Manager.”

“Based on staff interview, clinical record reviews and hospice policy reviews, the hospice failed to ensure the completion of a drug regimen review with the comprehensive assessment, within the first 5 days after election of the hospice benefit and at least every 15 days with the update to the comprehensive assessment for 2 of 19 sampled patients (Patients #2 and #15). Failure to ensure the Interdisciplinary Group (IDG) members involved in the assessment of patient needs completed all components of the drug regimen review (DRR) with each update to the comprehensive assessment increased the risk of unidentified side effects and actual or potential drug interactions. Findings include: 2. Patient #15 had a hospice admission date of 6/13/25 and received hospice services while residing in a nursing home. Clinical record review revealed the following:a. The Interdisciplinary Group (IDG) meeting note on 7/9/25 revealed a new medication was started on 6/22/25, fleet enema extra 19 g(grams), 7 g/197 mL(milliliters) rectal enema, administer 1 application rectally once a day for constipation.b. The IDG meeting note on 7/9/25 revealed a new medication was started on 7/8/25, senna plus 50 mg(milligram) - 8.6 mg tablet, take 2 tab(s) orally once a day.The hospice failed to complete a drug regime review (DRR) when the new medications were added.In an interview on 10/14/25 at 4:08 PM, Staff C, Vice President of Clinical Services, reported that she could not find a DRR in the patient’s chart when each of these 2 medications were started. The above findings were reviewed with the Vice President of Clinical Services, Administrator, and Clinical Manager. According to the hospice policy titled Medication-Drug Regimen Review, last revised in February 2023, the drug regimen review (DRR) is completed at admission, with medication changes, changes in patient condition or at minimum of every 14 days. Documentation of the DRR is captured in the Interdisciplinary Group (IDG) note. The DRR addresses side effects of drug therapy, lab monitoring for associated drug therapies, actual or potential drug interactions, duplicate drug therapy and effectiveness of drug therapy. During an interview on 10/6/25 at 3:38 PM, Staff G, Registered Nurse (RN), stated a DRR is completed at admission, recertification and anytime there is a change to the patient’s medication. 1.Patient #2 had a hospice admission date of 6/27/25 and received hospice services while residing in an assisted living facility. Clinical record review revealed: a. The skilled nurse visit note, dated 9/6/25, completed by Staff I, RN, identified the RN contacted the doctor and received an order for Haloperidol 1 milligram (mg) tablets with instructions to give to the patient 1 tablet orally every 6 hours as needed for agitation but lacked documentation of a DRR at the start of the new medication. b. The IDG meeting note, dated 9/16/25, identified Haloperidol 1 mg started on 9/6/25 but failed to document completion of a DRR. The hospice failed to complete a DRR when medication changes occurred.”

“Based on staff interview, clinical record review and hospice policy review, the hospice failed to ensure hospice nurse members of the Interdisciplinary Group completed a comprehensive assessment every 15 days at a minimum for 1 of 3 expired sampled patients. (Patient #19) Failure by the hospice Interdisciplinary Group (IDG) registered nurses to update the comprehensive assessment at a minimum of every 15 days placed the patient at risk for ineffective staff collaboration and communication regarding patient’s effectiveness of treatments and interventions. Findings include: According to the hospice policy, titled Comprehensive Assessment, dated 7/19/23, patient, caregiver, and family progress towards desired goals (outcomes) and responses to care are reassessed as often as required by the patient’s condition, but no less frequently than every 15 days. Patient #19 had a hospice admission date of 10/21/24, a death date of 3/31/25 and received hospice services while residing in a skilled nursing facility. Clinical record review revealed: a. IDG update to the Plan of Care, dated 1/29/25, included primary diagnosis of chronic diastolic (congestive) heart failure and physician orders for skilled nursing services. b. Skilled nurse visit note, dated 2/6/25, included a comprehensive assessment. c. Skilled nurse visit note, dated 2/25/25, included a comprehensive assessment, 19 days after the last comprehensive assessment, 4 days later than the minimum required time frame. The hospice failed to complete a comprehensive assessment at a minimum of every 15 days. During an interview on 10/14/25 at 8:44 AM, Staff C, VP (Vice President) of Clinical Services, reported the chart was reviewed and she agreed the comprehensive assessment was completed later than the required time frame. The above findings were reviewed with the VP of Clinical Services, Administrator and Clinical Manager.”

“Based on staff interview, clinical record review and hospice policy review, the hospice failed to ensure the hospice plan of care included all necessary medications and treatments and/or an accurate order for all medications and treatments to meet the needs of the patient for 3 of 19 sampled patients. (Patients #8, #15 and #19). Failure to ensure the plan of care included physician orders for all necessary medications, treatments and complete orders for medications placed patients at risk to receive inappropriate treatment of symptoms. Findings include: 3. Patient #15 had a hospice admission date of 6/13/25 and received hospice services while residing in a nursing home. Clinical record review revealed the following:a. The plan of care (POC) dated 6/13/25 to 9/10/25 included orders for skilled nursing and hospice aide services. Oxygen was listed on the POC with a start date of 6/13/25 that read, “oxygen to be applied at (liter flow rate) per (mode of delivery) (continuous/prn (as needed) for (reason).”b. An aide intervention listed in the same POC revealed the patient had oxygen precaution, the patient had oxygen at 2L (liters)/nc (nasal cannula). The hospice failed to include a specific order for oxygen for the patient.In an interview on 10/15/25 at 8:32 AM, Staff B, Clinical Manager, reported that on 7/22/25 the incomplete oxygen order was noted after the case manager found it and discontinued. A new oxygen order was then written. The above findings were reviewed with the Vice President of Clinical Services, Administrator, and Clinical Manager. 2. Patient #8 had a hospice admission date of 10/29/24 and received hospice services while residing in a skilled nursing facility. Clinical record review revealed: a. The Plan of Care, dated 6/25/25 to 8/24/25 and 8/25/25 to 10/23/25, indentified the patient had a primary diagnosis of chronic obstructive pulmonary disease and included physician orders for skilled nursing services and medications including oxygen therapy at 2 liters per minute. The patient goals and hospice aide tasks included oxygen therapy 2 to 4 liters per minute. b. The IDG update to the plan of care, dated 8/12, 8/26/25, 9/9 and 9/23/25, included orders for oxygen therapy at 2 liters per minte and patinet goals and hospice aide tasks fro oxygen therapy 2 to 4 liters per minute. The clinical record failed to include a clarifiction order for oxygen administration. According to the hospice policy, titled Interdisciplinary Care Plan Process, dated 7/19/23, identified the plan of care consists of updates to the plan of care from IDG (Interdisciplinary Group) meeting minutes include changes to the medications, treatments, supplies, durable medical equipment, problems, interventions, goals, changes in frequencies of team services, prep notes, discussion notes and other elements of the care plan. 1. Patient #19 had a hospice admission date of 10/21/24, a death date of 3/31/25 and received hospice services while residing in a skilled nursing facility. Clinical record review revealed: a. IDG update to the Plan of Care, dated 3/26/25, included primary diagnosis of chronic diastolic (congestive) heart failure, physician orders for skilled nursing services and medications. b. Skilled nurse visit note, dated 3/30/25, included documentation oxygen saturation of 80% on room air, shortness of breath at rest, oxygen rate 4 liters continuously, and obtained order for oxygen 4 liters per nasal cannula for comfort. Clinical record failed to include an interim physician order for oxygen. During an interview on 10/14/25 at 8:44 AM, Staff C, VP (Vice President) of Clinical Services, reported the chart was reviewed and she agreed there was no order for oxygen.”

“Based on hospice staff interview, clinical record review, and agency policy, the hospice failed to ensure the interdisciplinary group (IDG) 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 (POC) for 7 of 9 patients reviewed with missed visits. (Patients #9, #11, #15, #17, #12, #8, and #13).Failure of the IDG to update the comprehensive assessment placed the patients at risk for ineffective staff collaboration and communication regarding patients’ status and effectiveness of treatments and interventions. Findings include: 6. Patient #8 had a hospice admission date of 10/29/24 and received hospice services while residing in aa skilled nursing facility. Clinical record review revealed: a. The POC, dated 8/25/25 to 10/23/25, identified the patient had a diagnosis of chronic obstructive pulmanary disease and included orders for volunteer visits 4 times a month, hospice aide, social worker and skilled nurse visits. b. The clinical record identified volunteer visit notes, dated 8/20/25 and 8/27/2 ( 2 times a month). c. The IDG meeting notes, dated 8/26/25 and 9/9/25, lacked documentation the IDG was notified of the missed volunteer visits for the month of August, 2025. d. The clinical record identified volunteer visit notes, dated 9/3/25 and 9/9/25 (2 times a month). e. The IDG meeting notes, dated 9/9/25, 9/25/25 and 10/7/25, lacked documentation the IDG was notified of the missed volunteer visits for the month of September, 2025. The hospice failed to provide hospice aide visits as ordered per the POC. 7. Patient #13 had a hospice admission date of 5/25/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POCs, dated 6/25/25 and 9/23/25 to 12/21/25, identified the patient had a diagnosis of end stage renal disease and included orders for skilled nursed visits 1 time a week and hospice aide and social worker visits. b. The clinical record identified no skilled nurse visit note documented the week of 8/24/25 to 8/30/25. c. The IDG meeting notes, dated 8/26/25 and 9/9/25, lacked documentation the IDG was notified of the missed skilled nurse visit for the week of 8/24/25 to 8/30/25. The hospice failed to provide skilled nurse visit as ordered per the POC. The surveyor reviewed the above information with the VP of Clinical Services, Administrator and Clinical Manager. 5. Patient #12 had a hospice admission date of 9/19/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care (POC), dated 9/19/25 to 12/17/25, identified the patient had a diagnosis of prostate cancer and included orders for hospice aide visits 2 times a week, social worker and skilled nurse visits. b. The clinical record identified a missed hospice aide visit on 10/1/25. c. The IDG meeting note, dated 10/7/25, lacked documentation the IDG was notified of the missed hospice aide visit for the week of 9/26/25 through 10/2/25. The hospice failed to provide hospice aide visits as ordered per the POC. 4. Patient #17 had a hospice admission date of 12/18/24, a death date of 4/9/25 and received hospice services while residing in a skilled nursing facility. Clinical record review revealed: a. IDG update to the Plan of care, dated 3/12/25, included primary diagnosis of Multiple Sclerosis and physician orders for complementary therapy (massage therapy) two times per month. b. IDG update to the Plan of care, dated 3/26/25, included documentation of 1 missed massage therapy visit for the month of March. Clinical record lacked documentation of a second massage therapy visit for the month of March or a reason why a second massage therapy visit was not completed. During an interview on 10/14/25 at 8:40 AM, Staff C, VP of Clinical Services, reported documents are supposed to be scanned into the electronic medical record within a month. The clinical record for Patient #17 was reviewed and she agreed there was no documentation regarding the second missed massage therapy visit for March. According to agency policy, Interdisciplinary Care Plan Process last revised 7/19/23, directed in part, the purpose of the policy was to provide care coordination and an interdisciplinary approach to care planning. Updates to the POC from IDG meeting minutes include changes to frequencies of team services. In an interview on 10/7/25 at 1:!5 PM, Staff B, Clinical Manager, reported that when visits are missed a note is put in the prep notes with the date/discipline. The prep notes are part of the IDG meeting note. Missed visits are also discussed daily at stand up/stand down meetings. Patient #9 had a hospice admission date of 5/29/25 and received hospice services while residing in a nursing home. Clinical record revealed the following: a. The IDG meeting minutes on 9/16/25 included orders for visits from a hospice volunteer 4 times per month. 1. Review of the clinical record revealed the hospice volunteer only visited the patient 2 times in September 2025. 2. The IDG meeting note on 9/30/25 failed to include discussion of the missed volunteer visit. b. The IDG meeting note on 98/16/25 included orders for weekly skilled nurse visits. 1. Review of the clinical record revealed the skilled nurse did not visit the patient in September 2025. 2. The IDG meeting note on 9/30/25 failed to include discussion of the missed skilled nurse visit. c. The IDG meeting note on 9/2/25 included an order for (spiritual) counselor visits 2 times per month. 1. Review of the clinical record revealed the patient only had 1 visit from the spiritual counselor in September 2025. 2. The IDG meeting note on 9/16/25 failed to include discussion of the missed spiritual counselor visit. 2. Patient #11 had a hospice admission date of 1/5/24 and received hospice services while residing in a nursing home. Clinical record revealed the following: a. The IDG meeting notes on 9/16/25 included orders for visits from a hospice volunteer 4 times per month. b. The clinical record revealed a hospice volunteer failed to visit the patient on 9/24/25. c. The IDG meeting notes on 9/30/25 failed to include discussion of the missed volunteer visit. 3. Patient #15 had a hospice admission date of 6/13/25 and received hospice services while residing in a nursing home. Clinical record review revealed the following: a. The IDG meeting note dated 9/2/25 included an order for skilled nursing visits one per week. 1. Clinical record revealed a skilled failed to visit the patient for the week of 9/5/25. 2. The IDG meeting note dated 9/16/25 failed to include discussion of the missed skilled nurse visit. b. The IDG meeting note on 8/6/25 included orders for 10-12 physical therapy (*PT) sessions from 8/1/25 to 8/31/25. 1. Review of PT documentation from 8/7/25 to 8/27/25 revealed the hospice failed to provide at least 10 PT session in August 2025.”

“Based on hospice staff interview, clinical record review, and agency policy, the hospice failed to ensure the registered nurse (RN) developed hospice aide instructions for patient care that were specific and individualized to the patient’s needs for 2 of 17 sampled patients receiving hospice aide services (Patients #2 and #15).Failure to identify specific tasks for the hospice aide to perform or a specific frequency for the task leads to the potential risk that patients may failed to receive necessary services ordered on the plan of care. Findings include: 2. Patient #2 had a hospice admission date of 6/27/25 and received hospice services while residing in an assisted living facility. Clinical record review revealed: a. The Plan of Care (POC), dated 9/3/25 to 12/1/25, identified the patient had a diagnosis of senile degeneration of the brain and included orders for hospice aide services 3 times a week. b. The aide care plan, dated 6/27/25, include aide instructions to ambulate the patient using assistive device (cane, crutches, walker, oxygen). The assignment did not include specific instruction on what device the aide should use when ambulating the patient. During an interview on 10/14/25 at 8:35 AM, the Vice President (VP) of Clinical Services identified the aide care plan does not give specific instructions as to what assistive device should be used when ambulating the patient. The hospice RN failed to include what specific device the aide should use when ambulating the patient. The above findings were reviewed with the VP of Clinical Services, Administrator and Clinical Manager. According to agency policy, Hospice Aide Services revised 11/15/23 directed, in part, hospice aide services are assigned based on the registered nurse case manager’s comprehensive assessment and reassessment of the patient’s personal care needs and ability to perform activities of daily living. The registered nurse case manager develops a written hospice aide care plan that provides instructions to the hospice aide of the care to be provided. The hospice aide care plan is reviewed a soften as necessary and at a minimum every fourteen (14) days by the registered nurse case manager. 1. Patient #15 had a hospice admission date of 6/13/25 and received hospice services while residing in a nursing home. Clinical record review revealed the following:a. The IDG meeting note on 9/2/25 revealed the patient no longer required oxygen as of 8/18/25.b. The hospice aide care plan interventions listed in the 9/2/25 IDG meeting note included oxygen precautions, the patient wears oxygen at 2 L(liters)/nc (nasal cannula), start dated 6/16/25.The hospice failed to update the hospice aide plan when oxygen was discontinued.c. The IDG meeting note on 9/2/25 revealed the patient was back to her baseline with ax1 (assist of 1 person with mobility).d. The hospice aide care plan interventions listed in the 9/2/25 IDG meeting note included that the patient required the assistance of 2 persons with transfers to the bed or wheelchair starting 6/27/25. The hospice failed to update the hospice aide care plan when the patient had a change in the amount of assistance she needed with transfers.”

“Based on hospice staff interview, hospice policy review and clinical record review, the hospice failed to ensure hospice aides provided care to patients only as directed by the Interdisciplinary Group (IDG) and according to the hospice aide care plan for 3 of 17 sampled patients receiving hospice aide services (Patients #5, #12 and #16). Failure to ensure that hospice aide services are provided only as ordered by the physician and according to the hospice aide care plan increased the risk that patients’ personal care needs were not adequately met. Findings include: 3. Patient #5 had a hospice admission date of 11/20/24 and received hospice services while residing in a skilled nursing facility. Clinical record review revealed: a. IDG update to the POC, dated 8/26/25, identified the patient had a diagnosis of Huntington’s disease and included physician orders for skilled nurse and hospice aide services. b. Hospice aide care plan, dated 9/19/25, identified the tasks of measure the patient’s weight by the 7th of the month. c. Hospice aide visit notes, dated 9/3/25, completed by Staff H, Hospice Aide, lacked documentation of the task to measure the patient’s weight. d. The hospice aide viist note, dated 10/10/25, completed by Staff H, Hospice Aide, included documentation of the task to measure the patient’s weight (3 days late). The hospice aide failed completed the task of obtaining the patient’s weight per the RN) assignment. The surveyor reviewed the above information with the VP of Clinical Services, Administrator and Clinical Manager. 2. Patient #12 had a hospice admission date of 9/19/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. IDG update to the Plan of Care (POC), dated 9/23/25, identified the patient had a diagnosis of prostate cancer and included physician orders for skilled nurse and hospice aide services. b. Hospice aide care plan, dated 9/19/25, identified the tasks of bed bath and shower. c. Hospice aide visit notes, dated 10/2/25 and 10/9/25, completed by Staff H, Hospice Aide, identified the task of bed bath completed and identified the task of shower completed. The visit note lacked documentation of the specific task completed, a bed bath or a shower. The hospice aide failed to identify the specific services provided as instructed by the Registered Nurse (RN) assignment. According to the hospice policy, titled Hospice Aide Services, dated 11/15/23, identified the registered nurse case manager develops a written hospice aide care plan that provides instructions to the hospice aide of the care to be provided. 1. Patient #16 had a hospice admission date of 6/12/24, a discharge date of 9/29/25 and received hospice services while residing in a skilled nursing facility. Clinical record review revealed: a. IDG update to the Plan of Care, dated 9/2/25, identified a primary diagnosis Alzheimer’s disease and orders for skilled nurse and hospice aide services. b. Hospice aide care plan, dated 6/13/24, identified the task weigh by the 7th of the month. c. Hospice aide visit note, dated 9/4/25, identified the task weigh by the 7th of the month as not required today. d. Hospice aide visit note, dated 9/8/25, identified the task weigh by the 7th of the month as completed, weight 172 pounds. The task was completed 1 day late. During an interview on 10/14/25 at 8:49 AM, Staff C, VP of Clinical Services, reported the clinical record was reviewed and she agreed the weight was obtained late.”

“Based on clinical record review, hospice policy review and staff interview, the hospice failed to document required hospice aide uspervision every 14 days when the patient receives skilled services in conjunction with the hospice aide services for 2 of 17 sampled patients (patients #13 and #19) with hospice aide services for 14 days or longer. Failure to ensure the supervision of hospice aide by registered nurses completed according to regulation increased the risk of agency staff not meeting the patinets’ personal care needs. Findings include: 2. Patient #19 had a hospice admission date of 10/21/24, a death date of 3/31/25 and received hospice services while residing in a skilled nursing facility. Clinical record review revealed: a. IDG update to the Plan of Care, dated 1/29/25, included primary diagnosis of chronic diastolic (congestive) heart failure and physician orders for skilled nursing and hospice aide services. b. Skilled nurse visit note, dated 2/6/25, included hospice aide supervision. c. Skilled nurse visit note, dated 2/25/25, included hospice aide supervision, 19 days after the last supervision, 5 days later than the required time frame. The surveyor reviewed the above information with the VP of Clinical Services, Administrator and Clinical Manager. According ot the hospice policy titled Hospice Aide Supervision, last revised 2/1/23, the Registered Nurse (RN) supervises hospice aides employed by the hospice and any aides working under contract. The nurse makes an on-site visit to the patinet’s home no less frequently than every 14 calendar days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the interdisciplinary team are as identified in the hospice aide care plan and meet the patinet’s needs. The hospice aide does not have to be present during this visit. During an interview on 10/7/25 at 1:15 PM the Clinical Manager stated the hospice aide supervision documented in the comprehensive assessment. 1.Patient #13 had a hospice admission date of 6/25/24, and received hospice services while residing in a private residence. Clinical record review revealed: a. IDG update to the Plan of Care, dated 8/13/25, included primary diagnosis of end stage renal failure and physician orders for skilled nursing and hospice aide services. b. Skilled nurse visit note, dated 8/20/25, included hospice aide supervision. c. Skilled nurse visit note, dated 8/4/25, included hospice aide supervision, 15 days after the last supervision, 1 days later than the required time frame. The hosopice failed to complete hospice aide supervision every 14 days. According to the hospice policy titled Hospice Aide Supervision, last revised 2/1/23, the Registered Nurse (RN) supervises hospice aides employed by the hospice and any aides working under contract. The nurse makes an on-site visit to the patient’s home no less frequently than every 14 calendar days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the interdisciplinary team are as identified in the hospice aide care plan and meet the patient’s needs. The hospice aide does not have to be present during this visit. During an interview on 10/7/25 at 1:15 PM the Clinical Manager stated the hospice aide supervision documented in the comprehensive assessment. 1.Patient #13 had a hospice admission date of 6/25/24, and received hospice services while residing in a private residence. Clinical record review revealed: a. IDG update to the Plan of Care, dated 8/13/25, included primary diagnosis of end stage renal failure and physician orders for skilled nursing and hospice aide services. b. Skilled nurse visit note, dated 8/20/25, included hospice aide supervision. c. Skilled nurse visit note, dated 8/4/25, included hospice aide supervision, 15 days after the last supervision, 1 days later than the required time frame. The hospice failed to complete hospice aide supervision every 14 days. 2. Patient #19 had a hospice admission date of 10/21/24, a death date of 3/31/25 and received hospice services while residing in a skilled nursing facility. Clinical record review revealed: a. IDG update to the Plan of Care, dated 1/29/25, included primary diagnosis of chronic diastolic (congestive) heart failure and physician orders for skilled nursing and hospice aide services. b. Skilled nurse visit note, dated 2/6/25, included hospice aide supervision. c. Skilled nurse visit note, dated 2/25/25, included hospice aide supervision, 19 days after the last supervision, 5 days later than the required time frame. The above findings wee reviewed with the VP of Clinical Services, Administrator and Clinical Manager.”

“Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure clinical records contained pertinent, up-to-date and complete information in a timely manner for 2 of 6 sampled patients with ancillary services (Patients #10 and #15). Failure to maintain accurate clinical records with current patient information increased the risk that hospice staff provided services without up-to-date information related to the patient’s condition and decreased the ability of hospice staff to communicate effectively in order to coordinate patient care. Findings include: 2. Patient #15 had a hospice admission date of 6/13/25 and received hospice services while residing in a nursing home. Clinical record review revealed the following:a. The interdisciplinary group (IDG) meeting note on 8/6/25 included orders for 10-12 physical therapy (PT) session from 8/1/25 to 8/31/25.b. The clinical record failed to included PT visit notes for visits held in August 2025. In an interview on 10/14/25 at 3:10 PM, Staff B, Clinical Manager, reported that the PT documentation from August 2025 should have been uploaded within 30 days.The above findings were reviewed with the Vice President of Clinical Services, Administrator, and Clinical Manager. According to the hospice policy, titled Clinical Records, last revised February 2023, clinical record documentation is accurate, timely, complete, readily accessible and systemically organized to facilitate retrieval. Entries are made in the clinical record for all services provided (both those services provided directly and through contracted providers). According to the hospice policy, titled Patient Record Integrity, last revised December 2023, staff using hard copy forms are expected to complete visit notes at the bedside, but no later than one week from the date of service to accommodate for unique challenges. Ideally, the form is submitted to the office the date of completion but no later than two business days after the date of the documentation. During an interview on 10/7/25 at 1:15 PM, Staff B, Clinical Manager stated hospice volunteers and hospice therapy providers are expected to complete and turn in handwritten documentation monthly to be scanned into the patient’s electronic medical record (EMR). 1.Patient #10 had a hospice admission date of 2/18/25 and received services while residing in a nursing home. Clinical record review revealed: a. The Plans of Care (POC), dated 5/19/25 to 8/16/25 and 8/17/25 to 10/15/25 identified the patient had a diagnosis of chronic diastolic (congestive) heart failure and included orders for volunteer services 4 times a month and music therapy services 4 times a month. b. The music therapy visit notes, dated 8/8/25, 8/15/25, 8/22/25 and 8/29/25, completed by Staff E, Music Therapist, identified the notes were scanned into the EMR on 10/14/25, 44 days late per agency expectation. c. The music therapy visit notes, dated 9/5/25, 9/11/25, 9/19/25 and 9/26/25, completed by Staff E, Music Therapist, identified the notes were scanned into the EMR on 10/14/25, 14 days late per agency expectation. d. The volunteer visit note, dated 8/29/25, completed by Staff F, Volunteer, identified the note scanned into the EMR on 10/14/25, 44 days late per agency expectation. The hospice failed to have all completed documentation for ancillary services placed in the EMR within the required timeframe. According to the hospice policy, titled Clinical Records, last revised February 2023, clinical record documentation is accurate, timely, complete, readily accessible and systemically organized to facilitate retrieval. Entries are made in the clinical record for all services provided (both those services provided directly and through contracted providers). According to the hospice policy, titled Patient Record Integrity, last revised December 2023, staff using hard copy forms are expected to complete visit notes at the bedside, but no later than one week from the date of service to accommodate for unique challenges. Ideally, the form is submitted to the office the date of completion but no later than two business days after the date of the documentation. During an interview on 10/7/25 at 1:15 PM, Staff B, Clinical Manager stated hospice volunteers and hospice therapy providers are expected to complete and turn in handwritten documentation monthly to be scanned into the patient’s electronic medical record (EMR). 1.Patient #10 had a hospice admission date of 2/18/25 and received services while residing in a nursing home. Clinical record review revealed: a. The Plans of Care (POC), dated 5/19/25 to 8/16/25 and 8/17/25 to 10/15/25 identified the patient had a diagnosis of chronic diastolic (congestive) heart failure and included orders for volunteer services 4 times a month and music therapy services 4 times a month. b. The music therapy visit notes, dated 8/8/25, 8/15/25, 8/22/25 and 8/29/25, completed by Staff E, Music Therapist, identified the notes were scanned into the electronic medical record (EMR) on 10/14/25, 44 days late per agency expectation. c. The music therapy visit notes, dated 9/5/25, 9/11/25, 9/19/25 and 9/26/25, completed by Staff E, Music Therapist, identified the notes were scanned into the EMR on 10/14/25, 14 days late per agency expectation. d. The volunteer visit note, dated 8/29/25, completed by Staff F, Volunteer, identified the note scanned into the EMR on 10/14/25, 44 days late per agency expectation. The hospice failed to have all completed documentation for ancillary services placed in the EMR within the required timeframe. 2. Patient #15 had a hospice admission date of 6/13/25 and received hospice services while residing in a nursing home. Clinical record review revealed the following: a. The interdisciplinary group (IDG) meeting note on 8/6/25 included orders for 10-12 physical therapy (PT) session from 8/1/25 to 8/31/25.b. The clinical record failed to included PT visit notes for visits held in August 2025. In an interview on 10/14/25 at 3:10 PM, Staff B, Clinical Manager, reported that the PT documentation from August 2025 should have been uploaded within 30 days. 2. Patient #15 had a hospice admission date of 6/13/25 and received hospice services while residing in a nursing home. Clinical record review revealed the following:a. The Plans of Care (POC), dated --- to --- and 8/17/25 identified the patient had a diagnosis of ----- and included orders for 10-12 PT visits from 8/1/25 to 8/31/25.b. The clinical record failed to includedPT visit notes for visits held in August 2025. In an interview on 10/14/25 at 3:10 PM, Staff B, Clinical Manager, reported that the PT documentation from August 2025 should have been uploaded within 30 days.The above findings were reviewed with the Vice President of Clinical Services, Administrator, and Clinical Manager.”

“Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure all documentation was completed timely and appropriately authenticated in accordance with accepted standards of practice and agency standards for 1 of 1 sampled patients with music therapy services (Patient #10). Failure to ensure all documentation was completed, dated and signed in a timely manner decreased the ability of hospice staff to communicate and coordinate patient care effectively and to provide safe, effective hospice services to its patients. Findings include: According to the hospice policy titled Clinical Records, last revised February 2023, clinical record documentation is accurate, timely, complete, readily accessible and systemically organized to facilitate retrieval. Entries are made in the clinical record for all services provided (both those services provided directly and through contracted providers). According to the hospice policy titled Patient Record Integrity, last revised December 2023, staff using hard copy forms are expected to complete visit notes at the bedside but no later than one week from the date of service to accommodate for unique challenges. During an interview on 10/7/25 at 1:15 PM, Staff B, Clinical Manager stated documentation should be completed the same day as the visit. a. The Plans of Care, dated 5/19/25 to 8/16/25 and 8/17/25 to 10/15/25, identified the patient had a diagnosis of chronic diastolic (congestive) heart failure and included orders for skilled nurse, social work, hospice aide, volunteer, chaplain and music therapy services. b. Music therapy visit note, dated 8/15/25, signed completed by Staff E, Music Therapist, 10/10/25, 56 days after the visit and 49 days late per agency policy. c. Music therapy visit note, dated 8/22/25, signed completed by Staff E, Music Therapist, 10/10/25, 49 days after the visit and 42 days late per agency policy. d. Music therapy visit note, dated 8/29/25, signed completed by Staff E, Music Therapist, 10/10/25, 42 days after the visit and 35 days late per agency policy. e. Music therapy visit note, dated 9/9/25, signed completed by Staff E, Music Therapist, 10/13/25, 34 days after the visit and 27 days late per agency policy. f. Music therapy visit note, dated 9/11/25, signed completed by Staff E, Music Therapist, 10/13/25, 32 days after the visit and 25 days late per agency policy. g. Music therapy visit note, dated 9/19/25, signed completed by Staff E, Music Therapist, 10/10/25, 21 days after the visit and 14 days late per agency policy. h. Music therapy visit note, dated 9/26/25, signed completed by Staff E, Music Therapist, 10/10/25, 14 days after the visit and 7 days late per agency policy. The agency failed to ensure timely completion of routine visit documentation. The above findings were reviewed with the Vice President of Clinical Services, Administrator and Clinical Manager.”

“Based on staff interview, clinical record review, review of nursing home medication administration records and policy review, the hospice failed to ensure hospice staff provided overall coordination of the hospice care in regards to the patient’s medications with the nursing home for 1 of 2 sampled patients (Patient #3) with a nursing home medication review. Failure to ensure the hospice staff provided overall coordination of the patient’s medications with the nursing home placed the patients at risk for receiving inadequate care and/or treatments needed to meet the individual needs of the patient. Findings include: According to the hospice policy titled Nursing Facility Care Plan, Coordination of Communication, last revised in April 2025, agency nurse case managers for patients are responsible for coordinating and implementing patient care plans in collaboration with members of the Interdisciplinary Group (IDG), facility representatives and the attending physician. During an interview on 10/7/25 at 3:38 PM, Staff G, Registered Nurse (RN), identified anytime an update or change to the patient’s plan of care occurs, the facility is notified via telephone call or in person regarding the update or change. Patient #3 had a hospice admission date of 10/3/25 and received hospice services while residing in a nursing home. Clinical record review revealed: The Plan of Care (POC), dated 10/3/25 to 12/31/25, identified the patient had a diagnosis of lung cancer, included IDG orders for skilled nursing services 2 times per week and included physician orders for medications. Review of the patient’s nursing home Medication Administration Record (MAR), dated 10/8/25, identified the following medication discrepancies with the hospice’s POC and Medication Profile for the patient: a. The hospice POC had an order for Acetaminophen 500 milligrams (mg) tablets with instructions to take 2 tablets orally every 6 hours as needed for mild pain. The hospice’s Medication Profile identified a start date for the medication, dated 10/3/25. The nursing home’s MAR had an order for Acetaminophen 325 mg tablets with instructions to give 2 tablets by mouth every 4 hours as needed for elevated temperature; pain. The nursing home MAR identified a start date for the medication, dated 10/3/25. b. The hospice POC had an order for Guaifenesin 100 mg/5 milliliters (ml) oral liquid with instructions to take 10 ml orally every 6 hours as needed for cough. The hospice’s Medication Profile identified a start date for medication, dated 10/3/25. The nursing home’s MAR lacked an order for this medication. c. The hospice POC had an order for Ondansetron 8 mg tablets with instructions to take 1 tablet orally every 8 hours for nausea or vomiting. The hospice’s Medication Profile identified a start date for the medication, dated 10/3/25. The nursing home’s MAR had an order for Ondansetron 8mg tablets with instructions to give 1 tablet by mouth every 6 hours as needed for nausea/vomiting. The nursing home’s MAR identified a start date for the medication, dated 10/3/25. Hospice staff failed to ensure the coordination of the patient’s medication with the patient’s nursing home. The above findings were reviewed with the Vice President of Clinical Services, Administrator and Clinical Manager.”