Adoration Hospice

“Based on interview, document review, and agency policy review, the Hospice Agency failed to ensure volunteer hours equaled five (5) percent (%) of the total patient care hours of paid employees and contract staff. This had the potential to affect all 30 patients currently receiving hospice services. Findings include: Review of the Hospice Agency’s pamphlet (undated) and provided by the agency revealed the agency provided volunteer services.Review of the “Hospice Volunteer Requirement Report” dated 05/01/25 to 05/21/26 and provided by the agency revealed the hours of volunteer services in January 2026 were 24 hours with a percentage of 3.55%. From February 2026 to 05/21/26 revealed no volunteer hours were provided for the last four months. Review of the “Performance Improvement Project (PIP)” dated 11/19/25 and provided by the agency revealed the agency would increase volunteer hours to above 5%. Goals included to increase volunteer hours to 4% by the end of November 2025 and to 5% by 12/31/25. Additionally, two volunteers were to be added in the month of November 2025. The “PIP” indicated the agency would meet once a week to discuss volunteer recruitment and assignment of volunteers. During an interview on 05/21/26 at 10:50 AM, the Director of Clinical Services/Backup Administrator (DCS/BA) revealed the agency currently did not have any volunteers providing any services to any of the 30 patients of the agency. The DCS/BA revealed the agency just hired a Volunteer Coordinator (VC) on 04/20/26. He/she revealed the last patient to receive any volunteer services was in January 2026. He/she confirmed since February 2026 there were no patients receiving volunteer services. The DCS/BA confirmed there was no documentation to show the agency had been meeting weekly as the “PIP” indicated. During an interview on 05/21/26 at 2:45 PM, the VC confirmed being hired as the VC on 04/20/26 and currently there were no volunteers providing any services. The VC revealed they had two potential volunteers they were hoping to start soon. Review of the Hospice Agency’s policy titled, “Volunteer Services” dated 09/01/22 revealed, “Purpose: To ensure that qualified volunteers provide appropriate services in accordance with the plan of care and hospice program needs. Policy: The hospice will provide volunteer services under the direction of a Volunteer Coordinator and with the assistance of trained hospice volunteers . . . Procedures: . . . 4. The Volunteer Coordinator will track the use of volunteers, the cost savings achieved, and that the hours of volunteer services will exceed 5% of the total patient care hours of paid and contracted hospice personnel.””

“Based on interview, record review, and review of agency policy, the Hospice agency failed to ensure discharge summaries were sent to the physician for two of two patients (Patient (P) 13 and P14) reviewed for discharge out of a total sample of 14. This had the potential for continuity of care not being met. Findings include: 1. Review of P13’s “Hospice Certification and Plan of Care,” provided by the agency, revealed a start of care date of 04/23/25 with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Review of the document from the local hospital titled, “Printable Discharge Form” dated 04/21/25 and provided by the agency revealed under the title “Referral Information” revealed the patient was referred to hospice services by a local hospital. The referral from the hospital listed an attending physician and a primary care physician (PCP). Review of P13’s agency’s “Discharge Summary,” dated 07/21/25 and provided by the agency, revealed P13 revoked hospice services on 07/21/25 due to being independent at home. The “Discharge Summary” revealed no evidence the summary was sent to the patient’s physician who would be taking over care of the patient. There was no evidence the agency attempted to find out who the patient’s physician was that would be taking over as care of the patient, so the discharge summary report could be sent in order to maintain continuity of care. The “Discharge Summary” listed the hospice agency’s Medical Director as the patient’s physician. 2. Review of P14’s “Hospice Certification and Plan of Care,” provided by the agency, revealed a start of care date of 04/15/26 with a primary diagnosis of lung cancer. Review of the hospital’s document (untitled) dated 04/13/26 and provided by the agency revealed the patient had been admitted to the local hospital on 04/13/26 and referred to hospice services on 04/15/26. Under the “Care Team and Communication” section revealed two physician’s names as providing care to the patient. Review of P14’s “Discharge Summary,” dated 04/30/26 and provided by the agency revealed P14 revoked hospice services on 04/29/26 due to requiring minimal assistance with transfers, Activities of Daily Living (ADLs), and ambulation. The “Discharge Summary” revealed no evidence the summary was sent to the patient’s physician who would be taking over care of the patient. There was no evidence the agency attempted to find out who the patient’s physician was that would be taking over as care of the patient, so the discharge summary report could be sent in order to maintain continuity of care. The “Discharge Summary” listed the hospice agency’s Medical Director as the patient’s physician. During an interview on 05/21/26 at 4:05 PM the Director of Clinical Services/Backup Administrator (DCS/BA) revealed she did not know how the discharge summaries were sent to the physicians of the patients who revoked hospice services. She confirmed that both patients attending physician was the Medical Director of the hospice agency and the Medical Director was no longer providing care to the patients after hospice services were revoked. During an interview on 05/21/26 at 4:20 PM the Regional Administrator revealed the discharge summaries were faxed to the physician who would be taking over care of the patients once they revoked hospice services. She revealed they had no documentation of faxes being sent for the two patients (P13 and P14). During an interview on 05/21/26 at 4:45 PM the Regional Compliance Officer (RCO) confirmed the agency did not attempt to find out who P13 and P14’s physicians were that would be taking over care of the patients. The RCO further confirmed the Medical Director of the Hospice Agency was not either patient’s physician since revoking hospice services. Review of the agency’s policy titled, “Discharge from Hospice Program,” dated 10/2019 and last updated on 01/30/26, revealed . . . “Discharge Criteria . . . 4. The patient and family/caregiver request discharge . . . 10. A copy of the discharge summary will be sent to the attending physician. If requested, the patient’s clinical record will be provided.””

“Based on interview, record review, and review of the Hospice agency policy, the agency failed to ensure discharge summaries included the complete care provided for two of two patients (Patient (P) 13 and P14) reviewed for discharges out of a total sample of 14. This had the potential for continuity of care not being met. Findings include: 1.Review of P13’s “Hospice Certification and Plan of Care,” provided by the agency, revealed a start of care date of 04/23/25 with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Review of P13’s “Visit Note Report” dated 07/14/25 and provided by the agency revealed the patient was seen by the Registered Nurse (RN). The assessment revealed the patient indicated their pain as severe, on the left side, continuous, rating the pain score of 10, with 10 being the most severe pain. The patient reported to the nurse that they had taken six doses of morphine in the last 24 hours. By the end of the visit, the patient reported their pain at an acceptable level. The patient declined to try and change medications. The “Visit Note” indicated the patient was at risk for falls due to cognitive impairment, impaired functional mobility, and was taking one or more medications that increased their fall risk. Review of P13’s “Visit Note Report” dated 07/16/25 and provided by the facility revealed the patient was seen by the RN. The assessment revealed the patient indicated their pain as severe on the left side of the abdomen, continuous, rating the pain score of 10. The patient reported to the nurse that they had taken six doses of morphine in the last 24 hours. The patient’s pain was not brought to or below their acceptable level of pain by the end of the visit. The patient said their pain will always be a 10. Review of P13’s “Visit Note Report” dated 07/19/25 and provided by the agency revealed the patient was seen by the RN as an as needed (PRN) visit. The assessment revealed the patient complained of pain to the right upper quadrant radiating to the right rib area. The patient rated the pain at a 10 and had taken eight doses of morphine in the last 24 hours with no relief. A new order was received to discontinue methadone and increase morphine. Patient and family were educated on the new orders. The patient’s assessment revealed the patient had one to two falls in the past month. The patient was now considered a high risk for falls. The Medical Director was notified of the patient’s abdominal pain and recent fall. Review of P13’s “Visit Note Report” dated 07/21/25 and provided by the agency revealed the patient was seen by the RN. The assessment revealed the patient was reporting severe pain and rated the pain a 10. The location of the pain was epigastric (upper abdomen) pain extending all around the chest to the back with each inspiration. The patient reported taking 12 doses of morphine in the last 24 hours with no relief. The patient’s pain was not brought to or below their acceptable level for pain at the close of the visit. The patient was noted to be inconsolable. The patient requested to go to the emergency room (ER). Review of P13’s “Client Coordination Note Report” dated 07/21/25 and provided by the agency revealed the patient had made two calls to the hospice office indicating they wanted to go to the ER. The patient was informed a nurse would be there in 30 minutes and the patient agreed to wait for the visit. Upon arrival the patient was anxious and complaining of pain at a 10 in the epigastric area radiating all around the trunk. The patient’s family member indicated the patient had been crying and repeating over and over again he/she wanted to go to a facility for skilled cared. The patient was informed medication changes could be made to achieve better pain control and the patient declined. The patient revealed they wanted to go to the hospital for diagnostic testing and wanted treatment for whatever they find. The patient was informed that he/she would need to revoke hospice and there was no guarantee they would be readmitted. The patient verbalized understanding. Revocation papers were signed. Review of P13’s agency’s “Discharge Summary,” dated 07/21/25 and provided by the agency, revealed P13 revoked hospice services on 07/21/25 due to being independent at home. However, visit notes indicated the patient wanted to go to the ER and go to a skilled care facility. The “Discharge Summary” included the patient’s diagnoses, code status, allergies, a medication list, and a plan of care. There was no evidence the “Discharge Summary” included any information regarding the patient’s severe pain and/or pain management, any information regarding falls, or a summary of patient education provided to the patient. During an interview on 05/21/26 at 4:05 PM the Director of Clinical Services/Backup Administrator (DCS/BA) confirmed the discharge summary for P13 did not include any information regarding the patients severe pain and/or pain management, fall information, or a summary of patient education. 2. Review of P14’s “Hospice Certification and Plan of Care,” provided by the agency, revealed a start of care date of 04/15/26 with a primary diagnosis of lung cancer. Review of P14’s “Visit Note Report” dated 04/16/26 and provided by the facility revealed the patient was seen by the RN. The assessment revealed the patient had a stage II pressure ulcer on the left Achilles tendon (above the heel) which was present upon admission. The depth description indicated partial thickness. The wound was cleansed with wound wash, patted dry, and zinc ointment was applied. Wound care was noted to be completed daily. Hospice to provide treatment at each visit. Caregiver to provide treatment between hospice visits. Review of P14’s “Discharge Summary,” dated 04/30/26 and provided by the agency revealed P14 revoked hospice services on 04/29/26 due to requiring minimal assistance with transfers, Activities of Daily Living (ADLs), and ambulation. The “Discharge Summary” dated 04/30/26 included the patient’s diagnoses, code status, allergies, a medication list, and plan of care. There was no evidence the “Discharge Summary” included the patient’s stage II pressure ulcer and the treatments provided, or a summary of patient education provided to the patient. During an interview on 05/21/26 at 4:05 PM the Director of Clinical Services/Backup Administrator (DCS/BA) confirmed the “Discharge Summary for P14 did not include any information regarding the patient’s stage II pressure ulcer that the agency was providing treatments to, or a summary of patient education provided to the patient.. Review of the agency’s policy titled, “Discharge from Hospice Program,” dated 10/2019 and last updated on 01/30/26, revealed, “Purpose: To establish standards and a process by which patients are discharged from the hospice program . . . Procedure: . . . 4. Documentation will be filed when a patient is discharged, transferred, or referred to another organization. Relevant information will include: . . . B. Physical and psychosocial status at time of transfer or discharge, including specific medical, psychosocial, or other problems requiring interventions or follow-up . . . G. Continuing symptom management needs, e.g., pain, nausea, dyspnea. J. Summary of patient education provided to the patient and his/her comprehension of that information. K. Instruction and referrals provided to the patient . . . 6. If the patient is discharged to the community, the organization will inform the family both verbally and in writing, including a timeline for discontinuation of services.””

“Based on observation, record review, and interview, the hospice agency failed to ensure all of the patient’s prescription and over-the-counter medications and supplements were reviewed as part of the comprehensive assessment for 2 of 2 patients with home visit observations (Patient #1, 2).Findings include: 1. The Medication Profile policy, revised 05/11/2020, indicated “… Upon admission to hospice, the admitting nurse will initiate a medication profile to document the current medication regimen, including over-the-counter (OTC) medications, nutrition supplements, herbal remedies, vitamins and minerals, and oxygen therapy… A drug regimen review will be performed at the time of the initial and comprehensive assessment, when updates to the comprehensive assessments are performed… and with the addition of a new medication…”2. During a home visit observation on 04/23/2025 at 10:47 AM, observed RN 1 provided care for Patient #1. Observed one bottle of Men’s One A Day Multivitamin tablets and one bottle of Men’s One A Day Multivitamin gummies both sitting on the dresser in the bedroom of Patient #1’s home where the RN visit took place.Review of Patient #1’s clinical record included a medication profile. The medication profile failed to include Men’s One A Day Multivitamin in either the tablet or gummy form.During an interview on 04/23/2025 at 11:59 AM, Person 3, a relative of Patient #1, relayed Patient #1 had been taking the Men’s One A Day Multivitamin tablets since prior to hospice admission but had switched to the Men’s One A Day Multivitamin gummies three days prior to the home visit observation due to issues with swallowing the large tablets.During an interview on 04/23/2025 at 4:18 PM, RN 1 indicated she does a medication reconciliation looking at the medication bottles in the patient’s home when the caregiver is available to go through them with her. RN 1 indicated all medications the patient is taking should be included in the agency’s medication list including over-the-counter medications and supplements. RN 1 further indicated the patient’s caregiver had not mentioned the Men’s One A Day Multivitamins when asked previously which medications Patient #1 was taking.3. During a home visit observation on 04/23/2025 at 1:25 PM, observed RN 2 provided care for Patient #2 at Entity 1, a skilled nursing facility. Obtained a current facility medication list from Person 1, an LPN employed at Entity 1. Person 1 relayed the skilled nursing facility staff was responsible for administering Patient #2’s medications.Review of Patient #2’s clinical record included a Medication profile. The facility medication list included but not limited to scheduled Calmoseptine ointment (a moisture barrier used to protect and help heal skin irritation) to be applied each shift with a start date of 08/07/2024, Clonidine patch (a blood pressure medication that can also be used to treat anxiety) to be applied every Thursday with a start date of 08/08/2024, Preparation H external cream 1% (a medication used to temporarily relieve swelling, burning, pain, and itching due to hemorrhoids, swollen veins in the lower rectum or anus) to be applied four times per day as needed with a start date of 08/29/2024, Seroquel oral tablet 50 milligrams (an antipsychotic medication used to treat schizophrenia, bipolar disorder, and depression) to be given one time per day with a start date of 02/21/2025, Tenormin oral tablet to be given one time per day with a start date of 08/08/2024, and Triamcinolone Acetonide external lotion 0.1% (a medication used to help relieve redness, itching, or other discomfort caused by skin conditions) to be applied every eight hours as needed with a start date of 08/07/2024. The agency medication list provided on 04/22/2025 at 3:39 PM failed to include scheduled Calmoseptine ointment, Clonidine patch, and Preparation H cream. The agency medication list included Seroquel 25 milligram tablet. The agency medication list failed to include the correct dosage of 50 milligrams of Seroquel. The agency medication list included Tenormin tablet to be given two times daily. The agency medication list failed to include the correct frequency of one time daily for Tenormin.The agency medication list included Triamcinolone Acetonide cream to be applied daily as needed. The agency medication list failed to include the correct frequency of every eight hours as needed.During an interview on 04/23/2025 at 4:23 PM, RN 2 indicated she reconciles medications for a patient residing in a facility by asking the facility nurse to print a medication administration record and comparing it to the agency’s medication list. RN 2 indicated all medications from the facility medication list should be included on the agency medication list including over the counter and prescription medications, creams, ointments, or any other medicated items. RN 2 indicated she must have overlooked the scheduled Calmoseptine and the frequency of the Triamcinolone Acetonide cream on the facility medication list. RN 2 indicated she had updated the agency medication list the day prior to the interview to include the Clonidine patch, Preparation H, the correct dosage of Seroquel, and the correct frequency of Tenormin.”

“Based on record review and interview, the hospice agency failed to ensure an initial bereavement risk assessment was documented for the bereavement contacts of 2 of 5 patient records reviewed (Patient #2, 3).Findings include: 1. The Bereavement Assessment policy, revised 05/11/2020, indicated “… On admission, the social worker or hospice registered nurse will complete a bereavement risk assessment that is given to the Bereavement Coordinator. At a minimum it will include… Patient and family/ caregiver loss issues… Survivor needs… Social, spiritual, and cultural factors… Referrals to be made… Grief risk factors and potential for pathological grief reactions…2. The Initial Assessment policy, revised 05/11/2020, indicated “… Admitting registered nurse will determine the other disciplines to complete the appropriate sections of the comprehensive assessment based on identified problems and needs during this initial assessment… Nursing and bereavement sections will always be identified…”3. Review of Patient #2’s clinical record included an election date of 06/29/2024. The clinical record failed to include a bereavement risk assessment for Patient #2’s bereavement contacts.During an interview on 04/22/2025 at 4:11 PM, the CM indicated there was no bereavement risk assessment in Patient #2’s clinical record.During an interview on 04/22/2025 at 4:48 PM, the CM indicated Chaplain 1 had not seen Patient #2 around the time of admission, so he did not complete the initial bereavement risk assessment. The CM further indicated the nurse who did the admission was no longer with the agency so she could not ask her about the missing initial bereavement risk assessment.During an interview on 04/23/2025 at 4:03 PM, Chaplain 1 indicated when he arrived at his initial visit with Patient #2 they declined his services so he did not complete an initial bereavement risk assessment.During an interview on 04/23/2025 at 4:48 PM, MSW 1 indicated she had completed an initial bereavement risk assessment for Patient #2 and indicated it should be found in the MSW visit note.4. Review of Patient #3’s clinical record included an election date of 02/26/2025. The clinical record failed to include a bereavement risk assessment for Patient #2’s bereavement contacts.During an interview on 04/22/2025 at 4:12 PM, the CM indicated there was no bereavement risk assessment in Patient #3’s clinical record.During an interview on 04/22/2025 at 4:47 PM, the CM indicated Chaplain 1 had completed a bereavement risk assessment for Patient #3 but had not entered it into the EMR.During an interview on 04/23/2025 at 3:59 PM, Chaplain 1 indicated he completed a bereavement risk assessment for Patient #3’s spouse on 02/27/2025 and on a child of Patient #3 a few visits later but had not entered it into the EMR because until recently the RN had been entering the initial bereavement risk assessments.During an interview on 04/23/2025 at 4:50 PM, MSW 1 indicated her understanding was the bereavement risk assessment was completed by the chaplain, and she was also told the RN always completes a bereavement risk assessment at admission.”

“It is required that the hospice must organize, manage, and administer its resources to provide the hospice care and services to patients, caregivers, and families necessary for the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This Condition was not met as evidenced by review of clinical records, interviews and observation which revealed the hospice failed to organize, manage, and administer its resources to provide the hospice care and services to patients, caregivers, and families necessary for the palliation and management of the terminal illness and related conditions [HSLG 5.I/L648]; Failed to ensure that the Registered Nurse (RN) provided coordination of patient care, continuous assessment of the patient and family’s needs, and implementation of the interdisciplinary plan of care [HCPC.19.I/L540]; Failed to ensure that all hospice care and services furnished to patients followed an individualized written plan of care [HCPC.91.I/L543]; Failed to ensure that an individualized written plan of care was prepared for each patient based on the comprehensive assessment [HCPC.21.I/L545]; Failed to ensure the patient’s clinical record contained all physician’s orders [HSIM.3. I/L678]; and Failed to ensure the clinical record contained correct information [HSIM.3. I/L676]. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.100: Organization and administration of services.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review, interview, and observation. In 3 of 4 (75%) home visit observations revealed that the agency provided medication profiles was not updated to include all the patient’s current medications. Policy# 2-004.1, titled Medication Profile (revised October 2019) sub-section one (1) stated in part, “Upon admission, the admitting nurse will initiate a medication profile to document the current medication regimen, including over-the-counter (OTC) medications, nutritional supplements, herbal remedies, vitamins and minerals, and oxygen therapy.” Sub-section three (3) stated in part that a drug regimen review will be performed at the time of the initial and comprehensive assessment when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication.” Sub-section four (4) stated, “During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver understand the medication regimen.” Sub-section five (5) stated in part, “Each patient will receive appropriate written material for specific medications he/she is receiving.” Home Visit 2/Clinical Record 2: The elected hospice benefit was dated 10/21/23 with a patient residing in a skilled nursing facility (SNF). During the home visit with the Registered Nurse (RN) [Personnel Record 3] on 12/5/2023 a medication regimen review was completed comparing the agency medication profile dated 12/5/2023 to the patient’s current SNF medication regimen. The SNF medication list dated 12/5/2023 stated in part, “Pink Bismuth Suspension two-hundred sixty-two (262) milligrams (mg) per fifteen (15) milliliters (ml) (262mg/15ml). Give thirty (30) milliliters (ml) by mouth every four (4) hours as needed for loose stool; “Potassium Chloride ER tablet extended release ten (10) milligrams (mg). Take one (1) tablet daily as a supplement. Colace Oral Capsule one hundred (100) milligrams (mg). Give one (1) capsule by mouth as needed (PRN) for constipation. The Pink Bismuth medication was not on the hospice agency medication profile or care plan dated 12/5/2023. The hospice agency medication profile stated in part, “Potassium Chloride extended-release tablet twenty (20) milligrams (mg). Take one (1) tablet daily. Colace Oral Capsule one hundred (100) milligrams (mg). Give one (1) capsule daily for constipation.” Home Visit 3/Clinical Record 3 The elected hospice benefit was dated 10/14/2023. During the home visit with the hospice aide [Personnel Record 4] on 12/5/2023 a medication regimen review was completed comparing the agency provided medication profile dated 12/5/2023 to the patient’s current medication regimen. The hospice agency medication profile contained a list of thirty-four (34) medications. The patient’s daughter and son provide care equally fifty (50) percent of the time. There were seven (7) bottles of current prescription and over-the-counter medications. The caregiver provided the patient’s daily medication pill box, which contained six (6) medicines identified by different colors and shapes. The hospice agency medication profile stated in part, “Alka-Seltzer Extra Strength five-hundred (500) milligrams (mg). Dose said PER INSTRUCTION”, without any clear orders or directions on the medication profile; Calcium five hundred (500) milligrams (mg). Take one (1) tablet daily; Bisacodyl ten (10) milligram (mg) rectal suppository. Take one (1) suppository daily, Ativan two (2) milligram (mg) injection. Give one (1) milligram injection every four (4) hours for agitation; Esomeprazole Magnesium forty (40) milligrams (mg) without any directions for use; Glucosamine five-hundred (500) milligrams (mg). Take one (1) tablet daily. Hyoscyamine zero point one two five (0.125) milligrams. Take one (1) to two tablets every four hours as needed for increased secretions: Miralax seventeen grams. Take seventeen grams two times a day; Morphine ten milligrams per one milliliter injection(10mg/ml) injection. Take four milligrams by injection every four hours. Morphine concentrates one hundred milligrams per five milliliters (100mg/5ml). Take zero point two five (0.25) millimeters (ml) every four hours as needed (PRN) pain. The caregiver reported the patient used to take the medication Alka-Seltzer but no longer takes it and has not for “quite a while; no longer took Calcium; have never used a suppository, and there are no suppositories in the home; and has never used any medication that had been injected. The caregiver confirmed the patient did not take the medications Ativan, Esomeprazole, Hyoscyamine, MiraLAX, Morphine injection, or morphine concentrate. The caregiver did ensure the patient used to take glucosamine, but it was unclear if glucosamine was one of the medications in the daily pill box that the patient takes. The caregiver stated, “She has never used morphine or been on morphine. We do not have any morphine here in the home. The caregiver confirmed the hospice agency did not provide the patient or caregiver with an active medication list. A joint record review, observation, and interview with the Area Director of Clinical Operations on 12/5/2023 confirmed that the hospice agency did not provide the caregiver with written medication instructions or a current medication profile. The Area Director of Clinical Operations asked the caregiver, “Would it be helpful if I have the nurse bring you a current medication list?” the caregiver responded, “Yes. The Area Director of Clinical Operations reported on 12/7/2023 that the RN conducted a medication reconciliation following the site visit. The medication profile for the patient with a hospice benefit election date of 10/14/2021 (record 3) was now up to date—the medication profile contained twenty-four (24) medications. After reviewing the medication list provided, it was identified that the medication profile list dated 12/7/2023 still had the injectable medication of Ativan. The Area Director of Clinical Operations stated, “I need to take that off of there”. Home Visit 4/Clinical Record 4: The patient election of the hospice benefit was dated 10/6/2023 and resided in Assisted Living Facility (ALF). During the home visit with the Chaplain [Personnel Record 7] on 12/5/2023 a medication regiment review was completed comparing the hospice agency provided medication profile dated 12/5/2023 to the patient’s current ALF medication administration record/ medication list. The ALF medication list stated in part, “ Ocuvite Adult fifty (50) plus. Two-hundred fifty (250) milligrams (mg). Give one (1) cap once a day—Diclofenac sodium one (1) percent (%) (1%) gel. Apply one (1) application two (2) times (x’s) daily. Lorazepam Intensol two (2) milligrams (mg) per one (1) milliliter (ml) (2mg/ml). Take zero point two five (0.25) milliliters (ml) every four (4) hours as needed (PRN) for restlessness. Morphine Concentrate one hundred (100) milligrams (mg) per five (5) milliliters (ml) (100mg/5ml). Take zero point two five (0.25) milliliters (ml) every four (4) hours as needed (PRN) for pain. The hospice agency provided medication profile dated 12/5/2023 did not include Ocuvite Adult fifty (50) plus, Diclofenac one percent (1%) gel, Lorazepam Intensol, or Morphine concentrate. In addition, the ALF medication profile stated in part, “Sinemet (carbidopa-levodopa) twenty-five (25) -one hundred (100). Take one half (1/2) tablet three (3) times a day. The hospice agency profile stated in part, “Sinemet (carbidopa-levodopa) twenty-five (25) -one hundred (100). Take one (1) tablet three (3) times a day for Lewy body dementia. A joint record review, observation, and interview with the Area Director of Clinical Operations on 12/5/2023 confirmed that the hospice agency’s medication profiles did not match the medication profiles in the home, SNF and ALF.”

“It is required that the hospice designate registered nurse that is a member of the interdisciplinary group provided coordination of care and to ensure continuous assessment of each patient’s and family’s needs and implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review, document review, interview, and observation. In 4 of 19 (21%) clinical records reviewed revealed that the agency did not ensure the coordination of care, the continuous assessment of each patient’s and family’s needs, and the implementation of the interdisciplinary plan of care. Policy# 1-006.1 titled Care/Coordination (revised October 20219) sub-section purpose stated in part, “To ensure the coordination of services for each patient and to minimize the potential for missed, conflicting, or duplicated services.” Sub-section four (4) stated in part, “Care coordination will include, but not be limited to (A) clearly outlining each clinician’s responsibilities, (E timely documentation of coordination of care activities, (II Integration of services, whether services are provided directly or under the arrangement to the identification of patient needs and factors that could affect patient safety and treatment effectiveness, (J) coordination of care delivery to meet the patient’s needs and involve the patient representative and caregivers, as appropriate in the coordination care activities. Policy# 2-004.1, titled Medication Profile (revised October 2019) sub-section procedure stated in part, “Upon admission to hospice, the admitting nurse will initiate a medication profile to document the current medication regimen, including over-the-counter (OTC) medications, nutrition supplements, herbal remedies, vitamins, and minerals, and oxygen therapy. A drug regimen review will be performed at the time of initial and comprehensive assessment when updated to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication. Sub-section four (4) stated in part, During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient/family/caregiver, as well as other clinicians, understand the medication regimen. This includes, but will not be limited to, (A) using the medication profile to evaluate the use of drugs in the home setting. (B) Using the medication profile to teach the purpose of the medication, dosages, routes, administration times, side effects, and contraindications. (C) Using the medication profile as a communication tool for other clinicians involved in care.” Clinical Record 1: A patient with a hospice benefit election date of 11/21/2023 had an RN comprehensive assessment on 11/22/2023, which stated in part, “BP 179/109, Son states she is starting patient back on her BP med lisinopril 2.5 milligrams (mg) daily. There was no documented evidence that the physician was notified of the elevated blood pressure. A joint record review and interview with the Area Director of Clinical Operations on 12/4/2023 confirmed the record did not contain evidence the physician had been updated about the blood pressure reading. Clinical Record 3/Home Visit 3: The patient’s election of hospice benefit was dated 10/14/2021. The hospice aide care plan dated 10/14/2023 by the RN included a visit frequency order of two times a week that is stated in part, “shampoo weekly, skin care weekly, shaving weekly, and perineal care weekly.”’ A home visit was conducted with a hospice aide {Personnel Record 4]. The hospice aide care plan dated 12/5/2023 ordered the hospice aide interventions: bathing/chair bath every visit, shampoo weekly, skin care weekly, shaving weekly, and perineal care weekly. The hospice aide was witnessed performing a shower, not a chair bath. In addition, the aide reported they provide a shower, shaving, shampoo, skincare, and perineal care every visit, even though it is not on the care plan. The hospice aide stated, “I have told the RN about the care plan not being correct multiple times, and nothing gets done, so I just document the chair bath. The hospice aide care plan dated 12/3/2023-1/31/2023 stated in part, “bathing (chair/bath) every visit, shampoo weekly, skin care weekly, shaving weekly, and perineal care weekly.” The hospice aide stated, “ I give her a shower or a bath in her wheelchair. It’s whatever the patient wants. Most of the time, I shower her. I do not know why the care plan says a chair bath. Also, I shave her every visit because she is very self-conscious about her whiskers.” The hospice aide completed the task of shaving the patient assisting with transfer from the wheelchair to the shower. The hospice aide showered the patient, assisted with transfer from the shower chair to the wheelchair, and then assisted with dressing the patient. The tasks of assisting with transfer from the wheelchair to the shower and from the shower to the wheelchair and assisting with dressing were not on the hospice aide’s plan of care. The Hospice Aide documented on aide visits dated 11/24/2023, 11/17/2023, and 12/1/2023, the patient received a shower, not a chair bath. There was no documented evidence the RN was notified that a shower was given. Clinical Record 6: The patient elected hospice benefit was dated 10/12/2023. The aide plan of care by the RN dated 10/12/2023 included a visit frequency order of three times a week and stated in part, “shower to be performed weekly.” The week of 10/15/2023 the patient received one home health aide visit. There was no documented evidence that the aide completed a missed visit notification or notified the RN for two missed visits that week. On 10/26/2023, the Administrator entered a physician order that stated D/C HA visits were scheduled for 10/18/2023 and 10/20/2023. There was no documentation for the reason for the missed hospice aide visit, nor was there documented evidence the physician was notified. The week of 10/22/2-23-10/28/2023, the patient received a hospice aide visit on 10/24/2023 completed by the RN, documenting the patient refused the shower. The LPN entered a missed visit but did not specify the missed visit discipline for the date of 10/20/2023. The Area Director of Clinical Operations [Personnel 1] stated on 12/6/2023 that she believed the LPN was most likely entering the missed visit for the hospice aide visit, but the documentation did not include the missed discipline documentation information, and the Area Director of Clinical Operations confirmed the missing documentation. The clinical record contained a physician order dated 11/10/2023 entered by the Area Director of Clinical Operations that stated, “D/C HHA (discontinue hospice aide) visits on 10/25/2023 and 10/27/2023). Clinical Record 12: A patient with a hospice benefit election date of 5/23/2023 with a Plan of Care dated 8/21/2023-11/18/2023, included an order for Social Worker services one time monthly. The patient received a Social worker visit on 9/12/2023. There was no documented evidence of a Social Worker missed visit for the month of October 2023. The missed visit coordination note completed by the Social Worker on 11/29/2023 for the November missed Social Worker visit stated in part, “MSW attempted to contact the patient. Left a voicemail and left a message. No returned call. Unable to reschedule due to the end of month. A joint record reviews and interviews with the Area Clinical Director of Operations on 12/4/2023, 12/5/2023, 12/6/2023, and 12/07/2023 confirmed the hospice aide did not follow the plan of care; the hospice did not perform the wound care as ordered; there were no orders for wound care performed; confirmed the physician was not notified; and the records lacked missed visit documentation. The Executive Director presented a physician’s order dated 11/18/2023 entered by The Regional Compliance Officer, not the RN member of the Interdisciplinary Group (IDG) that stated in part, “Physician approval for Social Worker visit frequency Clarification for benefit period beginning 8/21/2023: effective 9/1/2023 1MO1”. The Executive Director reported that meant the patient wasn’t supposed to receive a Social Worker visit in October 2023. She stated, “I know the timeliness of this doesn’t meet our policy, but the Social Worker visit wasn’t really missed.” The Executive Director and Regional Compliance Officer, both confirmed it is the Hospice agency’s expectation that missed visits have both a missed visit note entered by the member of the IDG and a Physician’s order for the missed visit. A request was made for the policy or workflow concerning how missed visit documentation is supposed to be entered into the medical record but was not provided before the exit on 12/8/2023. The Executive Director stated, “There was a period at the end of October when we didn’t have a social worker, and we were just trying to meet our patients’ needs, and we weren’t focused on the paperwork part of it. That’s why we caught the missed visit eighteen (18) days later and entered the physician order. It is noted that the Regional Compliance Director entered the physician order dated 11/18/20.”

“It is required that the hospice designate a registered nurse that is a member of the interdisciplinary group to ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 19 (5%) records reviewed revealed that the hospice agency did not ensure the care and services followed the plan of care (POC). Clinical Record 10: A physician order dated 06/2/2023 stated in part, “skilled nurse or caregiver to clean wound number two (2) with soap and water. Pat dry. Apply Medi-honey to the open area and cover with foam dressing. Change every three (3) days and as needed (PRN) for soilage and skilled nurse to measure weekly. The patient received a Registered Nurse (RN) visit on 7/5/2023 and again on 7/22/2023 (16 days between SN visits). The Area Director of Clinical Operations confirmed the patient did not receive any skilled nurse visits for sixteen (16) days and confirmed the hospice did not perform the wound care as ordered.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals, and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 19 (11%) records reviewed revealed the hospice agency did not ensure that the plan of care contained all problems, goals, and interventions necessary for the palliation of the patient. Policy # 9-017.1, titled The Plan of Care (revised October 2019) procedure sub-section four (4) stated in part, “The plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and symptoms.” Sub-section twelve (12) stated in part, “The written plan of care will contain, but will not be limited to the following, (M) individualized interventions to assist with end-of-life care, (O) Statement of treatment goals and documentation of the progress of outcomes, (P) Information from the patient’s updated comprehensive assessment, (S) pain and symptom management interventions. Clinical Record 4: The election of hospice benefit was dated 10/6/2023. The Certificate of Terminal Illness (CTI) signed and dated 10/16/2023 stated in part, “ At this time, the patient is having issues with behaviors. The patient is suffering with paranoid delusions”. The initial Registered Nurse (RN) assessment dated 10/6/2023 stated in part, “Her disease process makes her paranoid and has given her hallucinations previously. She thinks the facility’s Director of Nursing (DON) does not like her, and it’s mutual. She complains that she cannot do things or needs assistance from her daughter but then tells caregivers that she does not need assistance.” There was no documented evidence on the Plan of Care dated 10/06/2023 that included the identified problem, interventions or goals for the hallucinations and behavior. Clinical Record 9: A patient elected the hospice benefit date on 11/19/2023. The Plan of Care (POC) included an order for skilled nurse visit frequency two times a week with Skilled nurse instructions/re-enforcement of tracheostomy care, including stoma care, suctioning, trach care, and dressing change. Skilled nurse to perform instruct/re-enforce to patient/caregiver wound care to closed incision/suture line daily or as ordered. The initial RN assessment dated 11/19/2023 identified “three wounds all surgical, G-tube, colon repair, and trach.” The wound assessment form identified one wound that was described as a “mid right abdominal right upper quad surgical incision.” The plan of care dated 11/19/2023 stated in part, During the week of 11/19/2023-11/25/2023, the patient received RN visits on Sunday 11/19/2023, Monday 11/20/2023, and Wednesday 11/22/2023. The RN visit notes dated 11/20/2023 and 11/22/2023 “stated in part, “wound care provided cleansed, covered with foam dressing Monday, Wednesday, and Friday. Tolerated without difficulty.” There was no documented evidence on the POC or in the clinical record for wound care orders to be performed by the SN. A joint record review and interview with the Area Director of Clinical Operations on 12/5/2023 confirmed the patient’s current plan of care dated 12/5/2023, and the original care plan dated 10/6/2023 did not contain any problems, goals, or interventions related to hallucinations or behaviors. A joint record review and interview with the Area Director of Clinical Operations on 12/6/2023 confirmed the patient’s plan of care dated 12/6/2023 did not contain any orders for wound care completion. However, it did have an intervention for teaching regarding trach care and dressing change. In addition, the Area Director of Clinical Operations confirmed the RN completed wound care without a physician’s wound care order on 11/20/2023 and 11/22/2023.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions, such as Hand hygiene. This standard was not met as evidenced by document review, interview, and observation. In 1 of 4 (25%) home visits revealed the hospice agency did not ensure that accepted hand hygiene practices were adhered to. Policy# 7-009.1 titled Hand Hygiene (revised October 2019) sub-section three (3) stated in part, “hand decontamination will be performed using an alcohol-based hand rub (D) after contact with body fluids or excretions, mucous membranes, non-intact skin, and if hands are not visibly contaminated.” Home Visit 3: A home visit was conducted on 12/5/2023 with a hospice aide [Personnel Record 4]. The hospice aide donned gloves and then shaved the patient while the patient was in the wheelchair. With donned gloves, the aide showered and performed peri care for the patient. After the shower, the aide opened the bathroom door and laundry room door and removed clothes from the dryer without changing gloves or hand sanitizing. The aide returned to the bathroom and dressed the patient with the same gloves. The aide was not observed to perform hand hygiene or change gloves after the initial pair of gloves were donned. The Area Director of Clinical Operations present at the visit confirmed that not changing gloves or performing hand hygiene did not adhere to the agency’s hand hygiene policy.”

“It is required that a hospice aide provide services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review, document review, interview, and observation. In 4 of 14 (28%) records reviewed where hospice aide services were accepted revealed that the hospice agency did not ensure the hospice aide provided all services and tasks included in the plan of care. Policy # 9-017.1, titled, The Plan of Care (revised October 2019) policy sub-section, stated in part, “The care provided to the patient must be in accordance with the plan of care.” Clinical Record 2: The patient’s election of hospice benefit was dated 10/21/2023. The Plan of Care (POC) included an order for hospice aide two times a week. The hospice aide care plan by the Registered Nurse (RN) dated 10/21/2023 stated in part, “ Bathing/shower weekly, dressing weekly. A review of the hospice aide visits notes dated 10/30/2023 and 11/4/2023, revealed that the bathing/shower and dressing were marked as completed on each visit. Clinical Record 3/Home Visit 3: The patient’s election of hospice benefit was dated 10/14/2021. The hospice aide care plan dated 10/14/2023 by the RN included a visit frequency order of two times a week that’s stated in part, “shampoo weekly, skin care weekly, shaving weekly, and perineal care weekly.”’ A review of the hospice aide visit’s notes dated, 10/17/2023,10/20/2023 10/31/2023 and 11/03/2023 revealed that shampoo weekly, skin care weekly, shaving weekly, and perineal care weekly were all marked as completed on each visit. A home visit was conducted with a hospice aide [Personnel 4] at a private residence on 12/5/2023, in the presence of the Area Director of Clinical Operations [Personnel 1]. The hospice aide care plan dated 12/5/2023 ordered the hospice aide interventions: bathing/chair bath every visit, shampoo weekly, skin care weekly, shaving weekly, and perineal care weekly. The hospice aide was witnessed performing a shower, not a chair bath. In addition, the aide reported they provide a shower, shaving, shampoo, skincare, and perineal care every visit, even though it is not on the care plan. The hospice aide told and Director of Area Clinical Operations, “I have told the RN about the care plan not being correct multiple times, and nothing gets done, so I just document the chair bath. Clinical Record 6: The patient’s election of hospice benefit was dated 10/12/2023. The hospice aide care plan by the RN dated 10/12/2023 included a visit frequency order of hospice aide three times a week. The week of 10/15/2023-10/21/2023, the patient received an aide visit on received a hospice aide visit on 10/16/2023, and 10/20/2023. There was no documented evidence of the third visit for the week of 10/15/2023. A physician order entered by the Administrator, not the RN case manager, on 10/26/2023 stated in part, “D/C HA visits scheduled for 10/18/2023 and 10/20/2023.” The week of 10/22/2023-10/28/2023, the patient received a hospice aide visit on 10/24/2023 completed by the RN. There was no documented aide visit notes or missed visit notes for the other two visits. Clinical Record 12: The patient’s election of hospice benefit was dated 5/23/2023. The hospice aide care plan by the RN dated 8/21/2023-11/18/2023 included a hospice aide visit frequency order for the hospice aide to provide services three times a week. During the week of 8/20/2023-8/26/2023, the LPN who was assigned the hospice aide visit, entered a hospice aide missed visit note on 8/25/2023. There was no documented aide visit notes or missed visit notes for the other two visits. The week of 8/27/2023-9/2/2023, the LPN completed a missed hospice aide visit note on 8/27/2023. There was no documented aide visit notes or missed visit notes for the other two visits. A joint record review and interview with the Area Clinical Director of Operations on 12/4/2023 confirmed the hospice aide did not follow the plan of care because the patient did not receive the ordered number of hospice aide visits and there was no notification to the physician. The Area Director of Clinical Operations confirmed the company expectation is that hospice aides complete missed visit documentation, as well as having the RN Case Manager enter the physician order, but stated, “ I noticed missed aide visits on a calendar. I didn’t know the reason they were missed, but I tried to help the nurses with ancillary tasks, and that’s why I entered the physician order for the missed visits.” An interview with the Executive Director and Regional Compliance nurse occurred on 12/7/2023, and both employees stated that it is the company’s expectation a missed visit note is completed, and a physician’s orders are obtained.” A request was made for the documentation policy and workflow for hospice aide missed visits but was not provided the information before exit.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review, document review, interview, observation, and personnel record review. In 2 of 14 (14%) clinical records reviewed in which hospice aide services were provided revealed that the agency did not ensure the aide reported changes in the patient’s needs to the Registered Nurse (RN). Policy # 9-017.1, titled The Plan of Care … (revised October 2019) policy sub-section, stated in part, “The care provided to the patient must be in accordance with the plan of care. Procedure sub-section four (4) stated in part, “The plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and symptoms. It must detail the scope and frequency of services needed to meet the patient’s and family/caregiver needs.” Sub-section ten (10) stated in part, “Any change in the patient’s condition must result in a change in the plan of care prior to implementation of the new service.” Clinical Record 3/Home Visit 3: The patient’s election of hospice benefit was dated 10/14/2021. The hospice aide care plan dated 10/14/2023 by the RN included a visit frequency order of two times a week that’s stated in part, “shampoo weekly, skin care weekly, shaving weekly, and perineal care weekly.”’ A review of the hospice aide visit’s notes dated, 10/17/2023,10/20/2023 10/31/2023 and 11/03/2023 revealed that shampoo weekly, skin care weekly, shaving weekly, and perineal care weekly were all marked as completed on each visit. During the home visit with the hospice aide (Personnel Record 4), and in the presence of the Area Clinical Manager on 12/5/2023, the hospice aide care plan dated 12/3/2023-1/31/2023 stated in part, “bathing (chair/bath) every visit, shampoo weekly, skin care weekly, shaving weekly, and perineal care weekly.” The hospice aide stated, “ I give her a shower or a bath in her wheelchair. It’s whatever the patient wants. Most of the time, I shower her. I don’t know why the care plan says a chair bath. Also, I shave her every visit because she is very self-conscious about her whiskers.” The hospice aide completed the task of shaving the patient and assisting with transfer from the wheelchair to the shower. The hospice aide showered the patient, assisted with transfer from the shower chair to the wheelchair, and then assisted with dressing the patient. The tasks of assisting with transfer from the wheelchair to the shower and from the shower to the wheelchair and assisting with dressing were not on the hospice aide’s plan of care. A review of the hospice aide visits completed documentation on visits dated 11/24/2023, 11/17/2023, and 12/1/2023, the aide documented the patient received a shower, not a chair bath. The Area Director of Clinical Services phoned the hospice aide on 12/5/2023 to inquire about the documentation of completing a chair bath or a shower. The hospice aide said I had told the nurse about this many times, and she hadn’t changed it, so I just documented I had completed a chair bath even though I had completed a shower. Clinical Record 5: The patient’s election of hospice benefit was dated 8/17/2023. The hospice aide plan of care by the RN dated 08/20/2023 included a visit frequency order for the hospice aide two times a week and to: “assist with feeding every visit.” The hospice aide documentation on the 12/1/2023 hospice aide visit note, stated in part, “assist with feeding not completed.” There was no documented evidence in the clinical record that the RN was notified that the task was not completed. A joint record review and interview with the Area Clinical Director of Operations on 12/4/2023 and 12/5/2023, the Area Clinical Director of Operations confirmed the hospice aide did not follow the plan of care and did not notify the RN.”

“It is required that a patient’s clinical record containing past and current findings contains correct clinical information. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 19 (5%) records reviewed revealed the hospice agency did not ensure the clinical record contained correct information. Document 2: Policy# 6-022.1, titled Clinical Service/Data Collection (revised October 2019) sub-section three (3), stated in part, “Entries into the clinical/service record will be clear, concise, and specific statements of fact.” Clinical Record 6: The patient’s election of hospice benefit was dated 10/12/2203 and had a Certificate of Terminal Illness (CTI), which stated in part, “Patient (she) is a seventy-two (72) year old female being admitted to hospice with a terminal diagnosis of Chronic Respiratory Failure. The patient is presently ambulatory. Patient reports at this time, she is slowing down secondary to pain in her back. Most recent imaging showed there had been some shifting of the hardware in her back. The patient started on pain medication during her admission. He can recognize his wife and family only. The patient is bedbound. The patient is incontinent of bowel and bladder. Has a foley cath in place.” The initial RN assessment completed on 10/12/2023 stated in part, “The patient is alert and oriented times (X’s) three (3) and is ambulatory and independent. In addition, the patient is continent of bowel and bladder.” A joint record review and interview with the Area Director of Clinical Operations on 12/4/2023 confirmed the Certificate of Terminal Illness did not contain correct clinical information. The Area Director of Clinical Operations stated, “Oh, I see what he did. he entered two patients ’ CTIs in one record. We will get this fixed. This is a big deal.” On 12/7/2023, the Executive Director presented an addendum to the CTI dated 12/6/2023. The executive director stated, “Our medical director did not make a mistake and put two CTIs in one. This addendum corrects his incorrect pronoun usage.”. The Executive Director responded, “Our medical Director wrote on this addendum that the patient is bedbound but can walk with a walker, so they are bedbound and ambulatory.” The RN assessment dated 10/12/2023, which also stated the patient is ambulatory and independent and is continent of bowel and bladder. However, the certificate of Terminal Illness CTI reported the patient had a Foley catheter on admission. The Executive Director reviewed the medical record and stated, “Ya, I can’t find evidence of a catheter on admission.”, which confirmed the CTI contained incorrect information.”

“It is required that a patient’s clinical record includes, at a minimum, physician orders. This standard was not met as evidenced by clinical record review, document review and interview. In 4 of 19 (21%) records reviewed revealed the hospice agency did not ensure the patient’s clinical record contained all physician’s orders. Policy# 6-022.1 titled Clinical Service/Data Collection (revised October 2019) sub-section one (1) stated in part that the clinical record will be initiated and maintained for each patient and will include, at a minimum, (F) physician orders.” Policy# 6-022.1, titled Clinical Service/Data Collection (revised October 2019) sub-section six (6) stated in part, “Entries into the clinical/service record will be completed and synched within twenty-four (24) hours of the provision of care. Entries will not include pre-filled documentation of future care and services.” Clinical Record 1/Home Visit 1: The election of hospice benefit was dated 11/21/2023 had a Registered Nurse (RN) comprehensive assessment dated 11/22/2023, that stated in part, “BP 179/109, Son states she is starting patient back on her BP med lisinopril 2.5 milligrams (mg) daily. As of 12/4/2023, the record did not contain a physician’s order for any blood pressure medication or notification to the physician of the elevated blood pressure. During the home visit with the RN [Personnel Record 1] on 12/5/2023, a review of the medication profile revealed that the blood pressure medication Amlodipine had been added to the medication profile, as well as a physician’s order had been obtained for the medication Amlodipine in the clinical records. A joint record review and interview with the Area Director of Clinical Operations on 12/4/2023 confirmed the record did not contain evidence the physician had been updated about the blood pressure reading. The area Director of Clinical Operations confirmed they contacted the primary RN after the record review on 12/4/2023 and instructed the nurse to complete the care coordination concerning blood pressures medications. The area Director of Clinical Operations confirmed they contacted the primary RN after the record review on 12/4/2023 and instructed the nurse to complete the care coordination concerning blood pressures and medications. The Director of Clinical Operations stated that did not adhere to the hospice’s policy for which required care and documentation of care to be completed within twenty-four (24) hours. Clinical Record 4/Home Visit 4: The patient’s election of the hospice benefit was dated 10/6/2023 with the patient residing in an Assisted Living Facility (ALF). A home visit was conducted on 12/5/2023 with the Chaplain [Personnel Record 4]. The ALF facility binder contained a care coordination note dated 12/1/2023 that stated in part, “The patient was started on morphine but will need to be monitored because behaviors have been noted with medication changes.” The hospice medication list dated 12/5/2023 did not contain the medication morphine. The ALF medication administration record/list dated 12/5/2023 stated in part, “Morphine concentrate twenty milligrams per one milliliter (20mg/ml). Give zero point two five millimeters every four hours as needed (PRN) for pain. A review of the hospice clinical record revealed no documented evidence of a morphine order. A joint record review, observation, and interview with the Area Clinical Director of Operations on 12/5/2023 confirmed that the patient’s medication list, both past and current, did not contain the medication Morphine. In addition, they confirmed the hospice agency’s medical record did not contain a physician’s order for the medication Morphine. Clinical Record 6: The election of hospice benefit was dated 10/12/2023. The initial RN assessment dated 10/13/2023 stated in part, “He is on a regular diet but unable to eat due to nausea. Order sent for Zofran.” The medication profile dated 12/4/2023 did not contain the medication Zofran. There was no documented evidence in the clinical record that included a physician’s order for Zofran. A joint record review and interview with the Area Clinical Director of Operations on 12/4/2023 confirmed that the patient’s medication list, both past and current, did not contain Zofran. In addition, they confirmed the hospice agency’s medical record did not have a physician’s order for the medication Zofran. Clinical Record 9: The patient’s election of the hospice benefit was dated 11/19/2023. The Plan of Care (POC) included an order for skilled nurse visit frequency two times a week with Skilled Nurse (SN) instructions/re-enforcement of tracheostomy care, including stoma care, suctioning, trach care, and dressing change. Skilled nurse to perform instruct/re-enforce to patient/caregiver wound care to closed incision/suture line daily or as ordered. The initial RN assessment dated 11/19/2023 identified “three wounds all surgical, G-tube, colon repair, and trach.” The wound assessment form identified one wound that was described as a “mid right abdominal right upper quad surgical incision.” During the week of 11/19/2023-11/25/2023, the patient received two RN visits. The RN visit notes dated 11/20/2023 and 11/22/2023 “stated in part, “wound care provided cleansed, covered with foam dressing Monday, Wednesday, and Friday. Tolerated without difficulty. Tolerated without difficulty.” There was no documented evidence on the POC or in the clinical record for wound care orders to be performed by the SN. A joint record review and interview with the Area Clinical Director of Operations on 12/6/2023 confirmed the record contained no physician’s order for wound care.”

“It is required that drugs and biologicals are labeled and stored in accordance with state law and regulation, as well as accepted standards of practice. Labels include expiration date. This standard was not met as evidenced by interview and observation. The agency supply room inspection was completed on 12/5/2023 in the presence of the Area Director of Patient Care Services. The following items were identified as expired: eight (8) Foley catheters size twenty-two (22) French with an expiration date of 7/28/2023, five (5) with an expiration date of 10/2023, one (1) calcium alginate dressing with an expiration date of 6/2022, and one (1) non-adhering dressing with an expiration date of 11/2023. The Area Director of Clinical Operations confirmed the expired supplies and stated it is everyone’s responsibility to check the supply room for expired supplies. A supply room inspection was completed on 12/5/2023 in the presence of the Area Director of Patient Care Services. The following items were identified as expired: eight (8) Foley Catheter size twenty-two (22) French with an expiration of 7/28/2023, five (5) with an expiration of 10/2023, one (1) Calcium Alginate Dressing with an expiration of 6/2022, and one (1) Non-Adhering Dressing with an expiration of 11/2023. The Area Director of Clinical Operations (staff 1) confirmed expired supplies. They reported it is everyone’s responsibility to check the supply room for expired supplies. There was no formal process to ensure supplies were checked for expired supplies.”