Serenity Hospicecare

“Based on policy review, after-hours call log review, record review, and interview, the hospice provider failed to ensure spiritual counseling services were available to assist the patient and family in minimizing the stress and problems that arose from their terminal illness in one of three patient records reviewed (Record/Patient # 3). This deficient practice has the potential to affect the provision of spiritual counseling to all the provider’s patients. Findings included: Review of the provider’s policy titled, “Scope of Core Services,” updated 05/23/2025, showed, in part:- The chaplains and spiritual counselors are available Monday through Friday 8am-5pm for routine patient visits, phone calls, assigned patient urgent and emergent needs, as well as any other duties assigned by the Director of Spiritual Services;- The Spiritual Care department is available 24/7/365 (24 hours a day, seven (7) days a week, 365 days a year) via Director of Spiritual Services; and- Should an on-call spiritual need arise, a visit will be provided to the patient/family by available spiritual care staff, spiritual care volunteer, the Director, or patient’s personal spiritual leader, coordinated by the Chief Operating Officer or Social Work. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 08/04/2025 with a terminal diagnosis of stage four lung cancer. The patient lived in a long-term care facility (LTCF), was alert and oriented, and had a sibling and daughter who visited regularly. Further review of the clinical record showed an admission document, signed by the patient’s representative on 08/04/2025, titled, “(Named Hospice) Hospice Care Hospice Services”. The document included the following statement: “Chaplains provide spiritual support on a regular basis and as needed 24 hours a day, 7 days a week”. Review of the provider’s after-hours call log showed on 08/16/2025 (Saturday), the long-term care facility (LTCF) nurses called the provider at 10:34 AM to report the patient was requesting a chaplain visit and again at 11:05 AM to report the patient wanted to get baptized. On 08/17/2025 (Sunday) the LTCF nurses called the provider at 1:50 PM to report the patient’s daughter was at bedside and was upset that the chaplain had not yet visited the patient. A second call was placed by a different LTCF nurse at 1:57 PM, requesting a return call. Review of the provider’s registered nurse (RN) communication notes showed: - On 08/16/2025 at 11:30 AM, the RN documented that LTCF nurse called because the patient requested a chaplain visit to be baptized;- The RN left messages for both hospice chaplains via text and Mediprocity (a medical messaging application for electronic devices); - A second call came in from the LTCF nurse. They requested the chaplain visit and informed the provider the patient was afraid to go to sleep and had been awake for a day due to fear of dying before he/she was baptized; and- The nurse offered a nursing visit but the LTCF nurse declined. Review of the provider’s chaplain visit notes showed the chaplain failed to visit the patient on 08/16/2025. Review of the hospice RN visit note, dated 08/17/2025, showed the following narrative entry “Received call from SNF (skilled nursing facility/ LTCF) staff d/t (due to) concern for worsening infection in lower extremity and general disgruntlement that our chaplain is not available over the weekend. Addressed pt’s (patient’s) infectious (infection) and symptom concerns with change in medication regiment (regimen)” and “gave SNF nurse (named nurse) phone number to admin (administrator) on call per (his/her) request”. Review of the hospice chaplain visit notes showed the chaplain failed to visit the patient on 08/17/2025. During an interview on 09/23/2025 at 8:54 AM, the patient’s sibling stated that, during the weekend of 08/16/2025, the patient was panicking and wanted to be baptized. The LTCF staff tried to get in touch with the chaplain to come out to see him/her. The patient kept going to the LTCF nurses “every hour on the hour” but there was no chaplain on duty to see him/her from the hospice, and the nurse that took care of him/her at the LTCF was very upset that no one would come. He/she (the patient) was in a panic and wouldn’t sleep because he/she was afraid he/she would die before he/she was baptized. The patient’s sibling also stated that, if someone would have come out to see the patient when he/she first requested, he/she would have been able to calm down, but the initial trouble getting someone made him/her frantic and panicky. It was just a really bad weekend. They couldn’t get the chaplain because it was the weekend, but people have needs and die on weekends so he/she did not understand why they couldn’t come see the patient. It would have made that weekend seem not as bad if someone would have visited. The chaplain did come visit the following Monday and was very apologetic and very nice. He/she tried to arrange a time for a baptism but, by then, the patient just felt too bad to do it. During a telephone interview on 09/23/2025 at 9:20 AM, chaplain-A stated that he/she did remember getting calls about the patient because he/she was interested in baptism. Chaplain-A was not able to go see the patient but he/she did go to see the patient on Monday and Tuesday. He/she talked to the family, the following week, and they told him/her that another resident at the LTCF told the patient that his/her baptism was not valid because he/she was not fully submerged in water and that upset him/her. When chaplain-A was hired on, he/she was told he/she would not have to work on weekends and any weekend visits were at his/her discretion. He/she was in the process of resigning from his/her church and was in meetings. Since, he/she was told he/she did not have to work weekends, he/she did not even look at his/her work phone. The alternate administrator was the one who finally reached chaplain-A on his/her personal phone on Sunday afternoon and he/she explained the situation and why he/she could not go. During a telephone interview on 09/23/2025 at 10:24 AM, chaplain-B stated that, yes, he/she received a voicemail on a Saturday about someone who wanted to be baptized. He/she couldn’t remember the patient’s name. Chaplain-B was out of town that day (Saturday) but their secondary chaplain, (chaplain-A) was able to go in and do it on Monday (the patient was not baptized on Monday). When asked about the provider’s system to meet the after-hours spiritual needs of the patients, chaplain-B stated that the provider does not really have a system in place for after-hours calls, they just leave it up to them (chaplains A and B). They send both chaplains a text message when after hours calls occur and whoever is able to do the visit, goes to see the patient. During an interview on 09/23/2025 at 11:02 AM, the administrator stated that they had one and one-half chaplain positions and they couldn’t expect them to be available 24/7. They did not have a back-up system in place for weekend chaplain visits but he/she understood that the patient’s spiritual needs must be met, just like their after-hours nursing needs must be met.”

“Based on policy review, record review, home visit observation, and interview, the hospice provider failed to ensure:- Routine orders were individualized to address the patient’s needs (L0547);- There were measurable outcomes that would be anticipated from implementing and coordinating the plan of care (L0548);- The plan of care included the drugs and treatments necessary to meet the needs of the patient (L0549); - The patient’s progress toward outcomes and goals were specified in the plan of care (L0553); - Care and services were provided in accordance with the plan of care (L0555); and- The ongoing sharing of information between all disciplines providing care and services in all settings (L0557). The cumulative effect of these deficient practices has the potential to affect all the patients on service with the provider. .”

“Based on review of the provider’s Emergency Operation Plan (EOP), record review, and interview, the hospice provider failed to ensure all staff were provided emergency preparedness (EP) training in one of five personnel records reviewed (Employee #4). This deficient practice has the potential to affect the care and safety of all the patients served by the provider during an emergency.Findings included:Review of the provider’s undated EOP showed the following:- The current staff will be trained on the new and updated EOP at the time of its publication;- All new staff will be trained on the EOP in orientation; - Emergency preparedness (EP) training will be conducted annually; and- Documentation of the training on the EOP and annual EP training will be maintained by the human resource manager. EMPOYEE #4 (E-4):Review of E-4’s personnel file showed a hire date of 04/08/2020. The file failed to show evidence that emergency preparedness training was completed during orientation and failed to show training was completed every two years as required per federal emergency preparedness guidelines (the provider’s EOP showed they would train employees annually).During an interview on 05/07/2025 at 12:15 PM, the office manager stated that E-4 was not trained on emergency preparedness during new employee orientation and did not participate in the annual training. He/She also stated that they did not know that E-4 needed the training.”

“Based on policy review, record review, home visit observation, and interview, the hospice provider failed to ensure that the comprehensive assessment identified the physical and spiritual needs related to the terminal illness, that must be addressed to promote the hospice patient’s well-being in four of five records reviewed (Records/Patients #1, #3, #4, and #5). This deficient practice has the potential to affect the care provided to all the patients served by the provider.Findings included:Review of the provider’s policy titled, “Comprehensive Assessment,” updated 10/15/2024, showed the comprehensive assessment:- Identifies the need for physical, psychosocial, emotional, and spiritual care; - Will be completed and documented on each patient;- Will include all areas of hospice care related to the palliation and management of terminal illness and related conditions;- Will be updated, by a registered nurse, as frequently as the condition of the patient required, or no less than every 14 days;- Will be updated with changes that took place since the initial assessment; and- Will be updated with the patient’s progress toward desired outcomes and the patient’s response to care. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 03/20/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient had secondary diagnoses of type II (two) diabetes (a chronic disease that results in too much sugar in the blood) and osteoarthritis (a common joint disease that causes pain, stiffness, and loss of mobility). The patient resided at the home with his/her spouse.Review of the document titled, “RN Initial Assessment,” dated 03/20/25, failed to show the patient’s diabetes needs and failed to show a spiritual assessment. Review of the document titled, “Social Worker Visit,” dated 03/20/2025, failed to show a spiritual assessment. Review of the document titled, “Skilled Nursing (SN) Visit,” dated 03/24/2025, failed to show the patient preferences and/or spiritual concerns were discussed.Review of the document titled, “Chaplain Visit,” dated 03/27/2025, showed the chaplain spoke to the patient’s daughter about visits and failed to complete a spiritual assessment. Review of the document title, “ RN Comprehensive Assessment,” dated 04/17/2025, failed to show a spiritual assessment.During an interview on 05/08/2025 at 9:35 AM, the administrator stated that he/she would expect the nurse to complete the spiritual assessment during the initial assessment and during subsequent comprehensive assessments. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 04/08/2025 with a terminal diagnosis of prostate cancer. The patient had secondary diagnoses of, but not limited to, urinary retention, osteonecrosis of the jaw (a condition where bone tissue dies due to a lack of blood supply), and diabetes (a group of diseases that results in too much sugar in the blood). The patient resided in his/her own home with the assistance of his/her spouse. Review of the document titled, “RN (Registered Nurse) Hospice Initial Assessment,” dated 04/08/2025, showed in part that the patient had catheter (a sterile tube placed in the bladder to drain urine) that was changed on 03/31/2025 by the spouse, and was scheduled to be changed on 04/30/2025. The documentation failed to identify the type and size of the catheter. Review of the document titled, “RN Hospice Follow-Up Visit,” date 04/15/2025, showed in part that the patient’s spouse had begun using moisture barrier cream to the patient’s buttocks. Review of the assessment documentation failed to include an assessment of the patient’s buttocks. During a home visit observation on 05/06/2025 at 1:00 PM, the patient’s spouse stated during an interview that he/she:- Changed the patient’s catheter every four weeks and as needed; and- Checked the patient’s blood sugars daily. Review of the document titled, “RN Comprehensive Assessment,” dated 04/22/2025, showed in part the comprehensive assessment of the patient failed to contain: * Documentation of the type, size, and correct frequency of the patient’s catheter; * The correct frequency of monitoring of the patient’s blood sugar reading; and * An assessment of the patient’s blood sugar readings.RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 12/30/2024 with a terminal diagnosis of urinary bladder cancer. The patient had secondary diagnoses of, but not limited to, dementia (decline in mental capacity), and a history of urinary tract infections (UTIs). The patient resided in a memory care unit of a local assisted living facility (ALF).Review of the document titled, RN Hospice Recertification Assessment,” dated 03/21/2025, showed in part that the patient had: - No pain; and- The comprehensive assessment failed to contain documentation of: * A description of why pain was an active problem for the patient, and: * The visit narrative showed the patient had morphine (an opioid pain medication used for moderate to severe pain) and lorazepam (an antianxiety medication) on his/her medication list, and recently started on hydrocodone/acetaminophen (a narcotic medication used for pain) for increased pain; * An assessment of the pain causing the need to increase the pain medications; * The patient’s nutritional deficit and actions to improve his/her nutritional status; and * The behaviors and/or symptoms necessitating the initiation of lorazepam therapy.Review of the document titled, “RN Hospice Follow-Up Visit,” dated 04/11/2025, showed that the visit note failed to contain documentation of an assessment/discussion of patient’s spiritual needs as no was chaplain available.Review of the document titled, “RN Hospice Comprehensive Assessment,” dated 04/15/2025, showed in part that the documentation failed to contain documentation of: - The patient’s skin integrity; and- An assessment of the use of oxygen to treat the patient’s abnormal breath sounds. Review of the document titled, “MSW Hospice Follow-Up Visit,” dated 04/17/2025, showed in part, the clinician failed to document an assessment of the patient’s preferences and/or spiritual concerns.Review of the document titled, “RN Hospice Follow-Up Visit,” dated 04/22/2025, showed in part the visit note failed to contain documentation of skin and spiritual assessments. Review of the document titled, “Patient Care Order,” dated 04/22/2025, showed the patient was to use Aquaphor (an ointment used to treat skin irritation) topical ointment two times per day to forehead for dry skin. Review of the document titled, “RN Hospice Follow-Up Visit,” dated 04/25/2025, showed in part that the assessment failed to contain documentation of a skin assessment including, but not limited to, the dry flaky area on the patient’s forehead. Review of the document titled, “RN Hospice Comprehensive Assessment,” dated 04/29/2025, showed in part that the documentation failed to contain: - A skin integrity assessment that identified any areas of redness or dry-flaky skin (failed to identify if the patient’s skin was intact, reddened, or flaky);- The frequency and results of oxygen therapy; and- A pain assessment that identified the frequency of the patient’s pain and interventions to treat the patient’s pain.During a home visit observation on 05/06/2025 at 8:30 AM, a review of the facility medication administration record showed the patient had received doses of hydrocodone/acetaminophen (an opioid medication used to treat mild to moderate pain) on 04/02/2025, 04/03/2025, 04/04/2025, 04/23/2025, and 04/26/2025 for pain. RECORD/PATIENT #5:Review of the clinical record showed the patient admitted to hospice services on 03/07/2025 with a terminal diagnosis of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood). The patient had secondary diagnoses of, but not limited to, atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat), diabetes, and sleep apnea (a disorder characterized by pauses in breathing during sleep). The patient resided in his/her own home with the assistance of his/her spouse. Review of the document titled, “RN Hospice Initial Assessment,” dated 03/07/2025, showed in part that the documentation failed to show an assessment of the treatments and interventions to treat the patient’s diagnosis of sleep apnea, atrial fibrillation, and diabetes. During an interview on 05/08/2025 at 10:30 AM, the administrator and RN coordinator stated that they would expect the comprehensive assessment of the patient to include an assessment of:- All diagnoses that impact the care of the patient; and- The patient’s pain history including the use of pain medications. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 04/08/2025 with a terminal diagnosis of prostate cancer. The patient had secondary diagnoses of, but not limited to, urinary retention, osteonecrosis of the jaw (a condition where bone tissue dies due to a lack of blood supply), and diabetes (a group of diseases that results in too much sugar in the blood). The patient resided in his/her own home with the assistance of his/her spouse. Review of the document titled, “RN (Registered Nurse) Hospice Initial Assessment,” dated 04/08/2025, showed in part that the patient had a catheter (a sterile tube placed in the bladder to drain urine) that was changed on 03/31/2025 by the spouse, and was scheduled to be changed on 04/30/2025. The documentation failed to identify the type and size of the catheter. Review of the document titled, “RN Hospice Follow-Up Visit,” date 04/15/2025, showed in part that the patient’s spouse had begun using moisture barrier cream to the patient’s buttocks. Review of the assessment documentation failed to include an assessment of the patient’s buttocks. Review of the document titled, “RN Comprehensive Assessment,” dated 04/22/2025, showed in part the comprehensive assessment of the patient failed to contain:- Documentation of the type, size, and correct frequency of the patient’s catheter changes;- The correct frequency the patient’s blood sugar was monitored; and- An assessment of the patient’s blood sugar readings.Per an interview conducted during a home visit observation on 05/06/2025, the patient’s spouse stated that he/she:- Changed the patient’s catheter every four weeks and as needed; and- Checked the patient’s blood sugars daily. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 12/30/2024 with a terminal diagnosis of urinary bladder cancer. The patient had secondary diagnoses of, but not limited to, dementia (decline in mental capacity), and a history of urinary tract infections (UTIs). The patient resided in a memory care unit of a local assisted living facility (ALF).Review of the document titled, “RN Hospice Recertification Assessment,” dated 03/21/2025, showed in part that the patient had: - No pain; and- The visit narrative showed the patient had morphine (an opioid pain medication used for moderate to severe pain) and lorazepam (an antianxiety medication) on his/her medication list, and recently started on hydrocodone/acetaminophen (a narcotic medication used for pain) for increased pain; - The comprehensive assessment failed to contain documentation of: * A description of why pain was an active problem for the patient, and: * An assessment of the pain causing the need to increase the pain medications; * The patient’s nutritional deficit and actions to improve his/her nutritional status; and * The behaviors and/or symptoms necessitating the initiation of lorazepam therapy.Review of the document titled, “RN Hospice Follow-Up Visit,” dated 04/11/2025, showed that the visit note failed to contain documentation of an assessment/discussion of patient’s spiritual needs as no chaplain was available.Review of the document titled, “RN Hospice Comprehensive Assessment,” dated 04/15/2025, showed in part that the documentation failed to contain documentation of: - The patient’s skin integrity; and- An assessment of the use of oxygen to treat the patient’s abnormal breath sounds. Review of the document titled, “Medical Social Worker (MSW) Hospice Follow-Up Visit,” dated 04/17/2025, showed in part, the clinician failed to document an assessment of the patient’s preferences and/or spiritual concerns.Review of the document titled, “RN Hospice Follow-Up Visit,” dated 04/22/2025, showed in part the visit note failed to contain documentation of skin and spiritual assessments. Review of the document titled, “Patient Care Order,” dated 04/22/2025, showed the patient was to use Aquaphor (an ointment used to treat skin irritation) topical ointment two times per day to forehead for dry skin. Review of the document titled, “RN Hospice Follow-Up Visit,” dated 04/25/2025, showed in part that the assessment failed to contain documentation of a skin assessment including, but not limited to, the dry flaky area on the patient’s forehead. Review of the document titled, “RN Hospice Comprehensive Assessment,” dated 04/29/2025, showed in part that the documentation failed to contain: - A skin integrity assessment that identified any areas of redness or dry-flaky skin (failed to identify if the patient’s skin was intact, reddened, or flaky);- The frequency and results of oxygen therapy; and- A pain assessment that identified the frequency of the patient’s pain and interventions to treat the patient’s pain.During a home visit observation on 05/06/2025 at 8:30 AM, a review of the facility medication administration record showed the patient had received doses of hydrocodone/acetaminophen (an opioid medication used to treat mild to moderate pain) on 04/02/2025, 04/03/2025, 04/04/2025, 04/23/2025, and 04/26/2025 for pain. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 03/20/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient had secondary diagnoses of type II (two) diabetes (a chronic disease that results in too much sugar in the blood) and osteoarthritis (a common joint disease that causes pain, stiffness, and loss of mobility). The patient resided at the home with his/her spouse.Review of the document titled, “RN Initial Assessment,” dated 03/20/25, failed to show the patient’s diabetes needs and failed to show a spiritual assessment. Review of the document titled, “Social Worker Visit,” dated 03/20/2025, failed to show a spiritual assessment. Review of the document titled, “Skilled Nursing (SN) Visit,” dated 03/24/2025, failed to show the patient’s preferences and/or spiritual concerns were discussed.Review of the document titled, “Chaplain Visit,” dated 03/27/2025, showed the chaplain spoke to the patient’s adult child about visits and failed to complete a spiritual assessment. Review of the document titled, “RN Comprehensive Assessment,” dated 04/17/2025, failed to show a spiritual assessment. RECORD/PATIENT #5:Review of the clinical record showed the patient admitted to hospice services on 03/07/2025 with a terminal diagnosis of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood). The patient had secondary diagnoses of, but not limited to, atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat), diabetes, and sleep apnea (a disorder characterized by pauses in breathing during sleep). The patient resided in his/her own home with the assistance of his/her spouse. Review of the document titled, “RN Hospice Initial Assessment,” dated 03/07/2025, showed in part that the documentation failed to show an assessment of the treatments and interventions to treat the patient’s diagnoses of sleep apnea, atrial fibrillation, and diabetes. During an interview on 05/08/2025 at 10:30 AM, the administrator and RN coordinator stated that they would expect the comprehensive assessment of the patient to include an assessment of:- All diagnoses that impact the care of the patient; and- The patient’s pain history including the use of pain medications. During an interview on 05/08/2025 at 9:35 AM, the administrator stated that he/she would expect the nurse to complete the spiritual assessment during the initial assessment and during subsequent comprehensive assessments.”

“Based on policy review, record review, home visit observation, and interview, the hospice provider failed to ensure staff maintained an accurate and updated medication profile in three of five full records reviewed (Records/Patients #1, #3, and #4). This deficient practice has the potential to affect all the patients served by the provider. Findings included:Review of the provider’s policy titled, “Medication Ordering, Administration, Disposal, Medication Reconciliation, and Documentation Requirements,” updated 10/18/2024, showed in part the following:- All medications must be entered on the medication profile in the electronic medical record (EMR);- Medication reconciliation will be completed every 14 days;- The nurse will compare medication bottles to the medication list in the electronic medical record for patients residing in private homes; and- The registered nurse coordinator (RNC) will perform a medication reconciliation against the medication list in the EMR for patients residing in facilities; and- The nurse that completed the medication reconciliation will document in the EMR that the medication reconciliation was completed. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 04/08/2025 with a terminal diagnosis of prostate cancer. The patient had secondary diagnoses of, but not limited to, urinary retention, osteonecrosis of the jaw (a condition where bone tissue dies due to a lack of blood supply), and diabetes (a group of diseases that results in too much sugar in the blood). The patient resided in his/her own home with the assistance of his/her spouse. During a home visit observation on 05/06/2025 at 1:00 PM a comparison of the provider’s medication profile (PMP) to the medications in the patient’s home (MPH) showed: - The PMP showed the patient was taking metformin (a medication used to control diabetes) and the patient’s spouse reported he/she had not given the medication for over one week; and- A review of the patient’s medication bottles showed the patient was taking senna-s (a medication used to treat constipation), zinc tablets (a mineral supplement), and prednisone (used for inflammation). The PMP failed to contain orders for the senna-s, zinc, or prednisone. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 12/30/2024 with a terminal diagnosis of urinary bladder cancer. The patient had secondary diagnoses of, but not limited to, dementia (decline in mental capacity), and a history of urinary tract infections (UTIs). The patient resided in a memory care unit of a local assisted living facility (ALF).A comparison of the PMP to the facility’s medication administration record (MAR), for April 2025, showed the PMP contained orders for vitamin D3, and the MAR contained orders for vitamin D2. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 03/20/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient had secondary diagnoses of type II (two) diabetes (a chronic disease that results in too much sugar in the blood) and osteoarthritis (a common joint disease that causes pain, stiffness, and loss of mobility). The patient resided at the home with his/her spouse.Review of the document titled “Skilled Nursing Notes,” dated 04/17/2025 and 05/01/2025, showed a failure to review the medication profile.Observation on 05/06/2025 at 10:47 AM, showed the following medication discrepancies between the medications in the patient’s home and the PMP, printed 05/05/2025. The PMP failed to show the following:- Triad hydrophilic wound dressing (a zinc-oxide based moist wound dressing);- Caldesene (a body powder used to treat chafing and minor skin irritations);- Tums and Rolaids (antacid medications used to relieve heartburn and acid indigestion); and- Pepto-Bismol (a medication used to treat upset stomach, heartburn, indigestion, and diarrhea). Per interview conducted during the observation, the private caregiver stated that he/she applied the Triad hydrophilic ointment when the patient’s buttocks and inner thighs were red and applied the ointment after each shower. He/She applied Caldesene in the patient’s brief after toileting and on the patient’s skin after each shower. He/She stated that the Tums and Rolaids were given as needed for indigestion. He/She stated that the Pepto-Bismol was given to relieve the patient’s diarrhea.During an interview on 05/08/2025 at 9:35 AM, the registered nurse coordinator (RNC) stated that the medication reconciliation occurred weekly during the nursing visit and “as needed” when medication was discontinued or added. The RNC stated that he/she would expect the over-the-counter medications to be on the medication profile.”

“Based on policy review, record review, home visit observation, and interview, the hospice provider failed to complete an initial bereavement assessment of the needs of the patient’s family in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect all the provider’s patients. Findings included:Review of the provider’s policy titled, “Bereavement Program,” updated 03/26/2025, showed in part, the social worker will complete an initial bereavement risk assessment within five days of admission. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 03/20/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient had secondary diagnoses of diabetes (a group of diseases that results in too much sugar in the blood) and osteoarthritis (a common joint disease that causes pain, stiffness, and loss of mobility). The patient resided at the home with his/her spouse.Review of the document titled, “Social Worker Visit,” dated 03/20/2025, showed the patient lived at home with his/her spouse and had been married for 60 years. The social worker failed to complete a bereavement assessment for the patient’s spouse. The social worker completed a bereavement assessment for the adult child who was the primary emergency contact and documented as the primary caregiver and lived out of town. During an observation on 05/06/2025 at 10:05 AM, per conversation between the chaplain and the patient, the patient stated that he/she had been married for 60 years. He/she stated that the couple were “best friends” and had worked together on the farm.During an interview on 05/06/2025 at 2:35 PM, the bereavement coordinator stated that the initial bereavement assessment was completed for the primary caregiver, and they did not typically do a second bereavement assessment.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure medication orders with variable doses were individualized and specified a reason for administration in two of five full records reviewed (Records/Patients #1 and #5). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Medication Ordering, Administration, Disposal, Medication Reconciliation, and Documentation Requirements,” last updated 10/18/2024, showed in part that orders with various doses or frequencies shall specify a maximum dose or frequency and the reason for administration. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 04/08/2025 with a terminal diagnosis of prostate cancer. The patient had secondary diagnoses of, but not limited to, urinary retention, osteonecrosis of the jaw (a condition where bone tissue dies due to a lack of blood supply), and diabetes (a group of diseases that results in too much sugar in the blood). The patient resided in his/her own home with the assistance of his/her spouse.Review of the document titled, “Hospice Plan of Care,” dated 04/08/2025, showed in part orders for: - Ibuprofen (a medication used to treat mild pain) take two to three tablets every six hours as needed for mild pain. The order failed to be individualized and give a reason for the variable dosage of two to three tablets; and- Oxycodone (a medication used to treat moderate to severe pain) take one to two tablets every two hours as needed for breakthrough pain. The order failed to be individualized and give a reason for the variable dosage of one to two tablets.RECORD/PATIENT #5:Review of the clinical record showed the patient admitted to hospice services on 03/07/2025 with a terminal diagnosis of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood). The patient had secondary diagnoses of, but not limited to, atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat), diabetes, and sleep apnea (a disorder characterized by pauses in breathing during sleep). The patient resided in his/her own home with the assistance of his/her spouse. Review of the document titled, “Hospice Plan of Care,” dated 03/08/2025, showed in part an order for lorazepam (a medication used to treat anxiety) one to two tablets every four hours as needed for agitation/restlessness. The order failed to be individualized and contain a reason for taking one tablet versus taking two tablets.During an interview on 05/08/2025 at 10:00 AM, the administrator and registered nurse coordinator stated that they would expect medication orders to contain a reason for variable doses.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure the plan of care contained measurable outcomes in four of five records reviewed (Records/Patients #1, #3, #4, and #5). This deficient practice has the potential to affect the goals for all the provider’s patients. Findings included: Review of the provider’s policy titled, “Nursing Plan of Care Documentation,” last updated 10/21/2024, showed the policy failed to contain verbiage that the plan of care must contain measurable outcomes anticipated from implementing and coordinating the plan of care. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 04/08/2025 with a terminal diagnosis of prostate cancer. The patient had secondary diagnoses of, but not limited to, urinary retention, osteonecrosis of the jaw (a condition where bone tissue dies due to a lack of blood supply), and diabetes (a group of diseases that results in too much sugar in the blood). The patient resided in his/her own home with the assistance of his/her spouse. Review of the documents titled, “Interdisciplinary Group Meeting,” dated 05/07/2025, showed in part: - The plan of care failed to contain goals for: * The progression of the wounds on the patient’s arm, right hip, and coccyx (tailbone); * The indwelling catheter; and * Management of the patient’s secondary diagnoses of diabetes and urinary retention; and- The plan of care failed to contain measurable elements that demonstrate progression for the goals of spiritual comfort, meeting of the patient’s and family’s spiritual needs, personal care, skin integrity, healthful environment, independence, and optimal bowel function. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 12/30/2024 with a terminal diagnosis of urinary bladder cancer. The patient had secondary diagnoses of, but not limited to, dementia (decline in mental capacity), and a history of urinary tract infections (UTIs). The patient resided in a memory care unit of a local assisted living facility (ALF).Review of the documents titled, “Interdisciplinary Group Meeting,” dated 04/30/2025, showed in part: - The plan of care failed to contain goals for: * Management of the patient’s secondary diagnoses that related to the patient’s care; * Adequate nutrition; * Safety including fall and oxygen precautions; and * Prevent or minimize respiratory distress; - The plan of care failed to contain measurable elements that demonstrate progression for the goals of spiritual comfort, meeting of the patient’s and family’s spiritual needs, personal care, skin integrity, healthful environment, independence, and optimal bowel function. RECORD/PATIENT #5:Review of the clinical record showed the patient admitted to hospice services on 03/07/2025 with a terminal diagnosis of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood). The patient had secondary diagnoses of, but not limited to, atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat), diabetes, and sleep apnea (a disorder characterized by pauses in breathing during sleep). The patient resided in his/her own home with the assistance of his/her spouse. Review of the documents titled, “Interdisciplinary Group Meeting,” dated 04/30/2025, showed in part: - The plan of care failed to contain goals for: * Management of the patient’s secondary diagnoses that related to the patient’s care including but not limited to warfarin therapy and diabetes; * Adequate nutrition; * Safety including fall and oxygen precautions; and * Prevent or minimize respiratory distress; - The plan of care failed to contain measurable elements that demonstrate progression for the goals of spiritual comfort, meeting of the patient’s and family’s spiritual needs, personal care, skin integrity, healthful environment, independence, and optimal bowel function. During an interview on 05/08/2025 at 10:45 AM, the administrator and the registered nurse coordinator stated that they would expect the goals to be measurable. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 03/20/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient had secondary diagnoses of type II (two) diabetes (a chronic disease that results in too much sugar in the blood) and osteoarthritis (a common joint disease that causes pain, stiffness, and loss of mobility). The patient resided at the home with his/her spouse.Review of the document titled, “Hospice Plan of Care (POC),” dated 03/20/2025, failed to show individualized goals with measurable outcomes to address the patient’s:- Safe, personal care, and hygiene;- Skin integrity;- Maintenance of a clean, safe environment;- Optimal coping; - Acceptable pain level; and- Optimal bowel functioning.”

“Based on policy review, record review, home visit observation, and interview the hospice provider failed to ensure the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions in three of five full records reviewed (Records/Patients #1, #3, and #5). This deficient practice has the potential to affect the care planning for all of the provider’s patients.Findings included: Review of the provider’s policy titled, “Nursing Plan of Care and Documentation,” last revised 10/21/2024, showed in part that all medications, treatments, labwork, tests, x-rays, procedures and equipment will be included in the plan of care. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 04/08/2025 with a terminal diagnosis of prostate cancer. The patient had secondary diagnoses of, but not limited to, urinary retention, osteonecrosis of the jaw (a condition where bone tissue dies due to a lack of blood supply), and diabetes (a group of diseases that results in too much sugar in the blood). The patient resided in his/her own home with the assistance of his/her spouse. Review of the document titled, “RN (Registered Nurse) Hospice Initial Assessment,” dated 04/08/2025, showed in part that the patient had: - A spouse who performed all of the personal care activities for the patient, and prefilled and administered medications; - Missing teeth related to osteonecrosis of the jaw; - A catheter (a tube inserted into the bladder to drain urine) that was changed on 03/31/2025 by the spouse, and was scheduled to be changed on 04/30/2025; - Frequent constipation; and- A glucose monitor in the home and his/her spouse monitored a blood sugar reading as needed.Observation on 05/06/2025 at 1:00 PM, showed the patient had a skin tear to the right forearm, the clinician wiped the wound with skin prep (a pad that contains a solution that creates a protective barrier between adhesives, tapes, and the skin, reducing irritation and discomfort) and left open to air. Per interview conducted during the observation, the spouse stated that, and the clinician confirmed that: - The patient’s spouse changed the patient’s catheter every four weeks and as needed, he/she used a stat-lock (an adhesive securement device) to secure the catheter tubing; - The patient’s spouse monitored the patient’s blood glucose level daily; - The patient had osteonecrosis of the jaw and on occasion a tooth would fall out; and - The patient had a skin tear to the right forearm, the clinician wiped the wound with skin prep and left it open to air.Review of the documents titled, “Interdisciplinary Group Meeting,” dated 05/07/2025, showed in part the document failed to contain orders and treatments to address: - The change of the catheter every four weeks and as needed by the spouse; - Assessment of the patient’s diabetes including, but not limited to the monitoring of the patient’s blood sugars; - Osteonecrosis of jaw and teeth falling out; and- Treatment of the skin tear to the right forearm.RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 12/30/2024 with a terminal diagnosis of urinary bladder cancer. The patient had secondary diagnoses of, but not limited to, dementia (decline in mental capacity), and a history of urinary tract infections (UTIs). The patient resided in a memory care unit of a local assisted living facility (ALF).Review of the document titled, “RN Hospice Recertification Assessment,” dated 03/21/2025, showed in part that the patient had: - A high risk for the development of pressure ulcers; - Bowel and bladder incontinence (a loss of control of the bowel or bladder); - Bilateral leg edema (swelling of the tissues); - Oxygen as needed;- Moderately severe dementia; - No pain, however, pain is an active problem for the patient. The patient had narcotics and over-the-counter pain medications ordered. The patient was comfortable with the pain management regimen. The visit narrative showed the patient had recently started on hydrocodone/acetaminophen (an opioid medication containing an over-the-counter pain med used for mild to moderate pain) for increased pain. Morphine (an opioid medication used to treat moderate to severe pain) and lorazepam (an antianxiety medication) had also been initiated this month; and- A high risk for falls. Review of the document titled, “Interdisciplinary Group Meeting,” dated 04/23/2025 showed in part that the care plan failed to contain interventions and goals for the patient’s:- High fall risk; - High nutritional risk, including the staff having to assist with feeding each meal; - Pain;- History of urinary tract infections; and- Cardiorespiratory issues including wheezing and edema. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 03/07/2025 with a terminal diagnosis of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood). The patient had secondary diagnoses of, but not limited to, atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat), diabetes, and sleep apnea (a disorder characterized by pauses in breathing during sleep). The patient resided in his/her own home with the assistance of his/her spouse. Review of the document titled, “RN Hospice Initial Assessment,” dated 03/07/2025, showed in part the following: - Risk for skin breakdown;- Congestive heart failure with abnormal and diminished breath sounds bilaterally. Opioid treatment was initiated on this date. Edema in both hands with the skin appearing tight, and shiny;- Respiratory: sleep apnea, shortness of breath with exertion;- No bowel management program was initiated; - Endocrine: Diabetes, taking medications by mouth; and - High fall risk.Review of the document titled, “Interdisciplinary Group Meeting,” dated 04/30/2025, showed in part the plan of care failed to contain interventions and goals to address: - The patient’s risk of skin breakdown; - Congestive heart failure including, but not limited to the assessment of dyspnea and edema; - Respiratory issues including dyspnea and sleep apnea;- The patient’s high fall risk; - Diabetes; and- Monitoring of warfarin (a blood thinner) /therapy for atrial fibrillation.During an interview on 05/08/2025 at 10:45 AM, the administrator and the registered nurse coordinator stated that they would expect the plan of care to contain interventions and goals to address issues identified during the comprehensive assessment.”

“Based on policy review, record review, home visit observation, and interview the hospice provider failed to ensure the plan of care showed the patient’s progress toward goals in four of five full records reviewed (Records/Patients #1, #3, #4, and #5). This deficient practice has the potential to affect the goal progression for all the provider’s patients. Findings included: Review of the provider’s policy titled, “Nursing Plan of Care (POC) Documentation,” updated 10/21/2024, showed in part that the plan of care will be updated every two weeks during the IDG (interdisciplinary group) meeting. The plan of care should also be updated when clinically indicated. The policy failed to contain verbiage that the plan of care must reflect the patient’s progress toward goals. Review of the provider’s policy titled, “Interdisciplinary Team Meetings,” updated 11/01/2024, showed in part that the interdisciplinary team will be responsible for the development and updating all patient’s electronic plan of care. The policy failed to contain the verbiage that the plan of care must reflect the patient’s progress toward goals. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 04/08/2025 with a terminal diagnosis of prostate cancer. The patient had secondary diagnoses of, but not limited to, urinary retention, osteonecrosis of the jaw (a condition where bone tissue dies due to a lack of blood supply), and diabetes (a group of diseases that results in too much sugar in the blood). The patient resided in his/her own home with the assistance of his/her spouse. Review of the documents titled, “Interdisciplinary Group (IDG) Meeting,” dated 05/07/2025, showed in part the plan of care failed to contain documentation of the patient’s progress toward the goals of:- Family achieves spiritual comfort;- Patient and family will have spiritual needs met;- Patient’s personal care needs will be met;- Promote skin integrity; - Promote healthful environment;- Optimal independence; and- Patient will maintain optimum bowel functioning consistent with food intake and stage of disease process.RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 12/30/2024 with a terminal diagnosis of urinary bladder cancer. The patient had secondary diagnoses of, but not limited to, dementia (decline in mental capacity), and a history of urinary tract infections (UTIs). The patient resided in a memory care unit of a local assisted living facility (ALF).Review of the documents titled, “Interdisciplinary Group Meeting,” dated 04/30/2025, showed in part the plan of care failed to contain documentation of the patient’s progress toward the goals of:- Family achieves spiritual comfort;- Patient and family will have spiritual needs met;- Patient’s personal care needs will be met; - Promote skin integrity;- Promote healthful environment; and- Patient will maintain optimum bowel functioning consistent with food intake and stage of disease process. RECORD/PATIENT #5:Review of the clinical record showed the patient admitted to hospice services on 03/07/2025 with a terminal diagnosis of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood). The patient had secondary diagnoses of, but not limited to, atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat), diabetes, and sleep apnea (a disorder characterized by pauses in breathing during sleep). The patient resided in his/her own home with the assistance of his/her spouse. Review of the documents titled, “Interdisciplinary Group Meeting,” dated 04/30/2025, showed in part the plan of care failed to contain documentation of the patient’s progress toward the goals of:- Family achieves spiritual comfort;- Patient and family will have spiritual needs met;- Patient’s personal care needs will be met; - Promote skin integrity;- Promote healthful environment; and- Patient will maintain optimum bowel functioning consistent with food intake and stage of disease process. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 03/20/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient had secondary diagnoses of diabetes and osteoarthritis (a common joint disease that causes pain, stiffness, and loss of mobility). The patient resided at the home with his/her spouse.Review of the document titled, “Social Worker Visit,” dated 04/24/2025, showed the social worker delivered a medical alert device and provided instructions to the patient and private pay caregiver. Review of the document titled, “Interdisciplinary Group (IDG) Meeting,” dated 04/30/2025, showed the social worker reported concerns about the patient being home alone. The spouse lived in the home and had problems “getting up” on his/her own. The patient’s goal was to remain in his/her own home. A medical alert system had been ordered for the patient.Review of the document titled, “Registered Nurse (RN) Comprehensive Assessment,” dated 05/01/2025, failed to show the medical alert assistive device.Observation on 05/06/2025 at 10:10 AM, showed the patient was wearing a medical alert assistive device necklace. Per interview during the observation, the patient stated that if he/she had an emergency, he/she would push the “button” on the medical alert assistive device and the hospice agency would answer.During an interview on 05/08/2025 at 9:35 AM, the registered nurse coordinator (RNC) stated that he/she would expect the POC to identify the medical alert assistive device.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure that the care and services were provided in accordance with the plan of care in four of five full records reviewed (Records/Patients #1, #3, #4, and #5). This deficient practice has the potential to affect the provision of care to all of the provider’s patients. Findings included: Review of the undated provider’s policy titled, “Missed Visits Procedure,” showed in part:- If a visit is missed and cannot be rescheduled, it’s important to ensure the overall frequency of visits still meets the requirements of the plan of care; and- Missed visits should not be for staff convenience. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 04/08/2025 with a terminal diagnosis of prostate cancer. The patient had secondary diagnoses of, but not limited to, urinary retention, osteonecrosis of the jaw (a condition where bone tissue dies due to a lack of blood supply), and diabetes (a group of diseases that results in too much sugar in the blood). The patient resided in his/her own home with the assistance of his/her spouse. Review of the document titled, “Hospice Plan of Care (POC),” dated 08/08/2025, showed in part an order for nursing visits two times per week. Review of the document titled, “Skilled Nursing (SN) Visit,” dated 04/18/2025, showed that the nurse missed the patient visit related to a holiday and the office was closed. The SN failed to coordinate with the IDG to reschedule visits that fell on a holiday and failed to coordinate with the patient to offer a different visit day for that week. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 12/30/2024 with a terminal diagnosis of urinary bladder cancer. The patient had secondary diagnoses of, but not limited to, dementia (decline in mental capacity), and a history of urinary tract infections (UTIs). The patient resided in a memory care unit of a local assisted living facility (ALF).Review of the document titled, “Hospice POC,” dated 04/09/2025, showed in part an order for nursing visits two times per week. Review of the document titled, “SN Visit Note,” dated 04/18/2025, showed that the nurse missed the patient visit related to a holiday and the office was closed. The SN failed to coordinate with the IDG to reschedule visits that fell on a holiday and failed to coordinate with the patient to offer a different visit day for that week. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 03/20/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient had secondary diagnoses of diabetes and osteoarthritis (a common joint disease that causes pain, stiffness, and loss of mobility). The patient resided at the home with his/her spouse.Review of the document titled, “Hospice POC,” dated 03/23/2025, showed in part an order for aide visits three times per week. Review of the document titled, “Aide Visit,” dated 04/18/2025, showed that the aide missed the patient visit related to a holiday. The aide failed to coordinate with the SN and IDG to reschedule visits that fell on a holiday and failed to coordinate with the patient to offer a different visit day for that week. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 03/07/2025 with a terminal diagnosis of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood). The patient had secondary diagnoses of, but not limited to, atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat), diabetes, and sleep apnea (a disorder characterized by pauses in breathing during sleep). The patient resided in his/her own home with the assistance of his/her spouse.Review of the document titled, “Hospice POC,” dated 03/07/2025, showed in part an order for aide visits two times per week. Review of the document titled, “Aide Visit,” dated 04/18/2025, showed that the aide missed the patient visit related to a holiday and the office was closed. The aide failed to coordinate with the SN and IDG to reschedule visits that fell on a holiday and failed to coordinate with the patient to offer a different visit day for that week. During an interview on 05/08/2025 at 10:15 AM, the administrator and registered nurse coordinator stated that they had closed the office for the holiday on 04/18/2025, and they were unaware that they should not have missed visits for staff convenience.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure the ongoing sharing of information between all disciplines providing care and services in two of five full records reviewed (Records/Patients #2 and #3). This deficient practice has the potential to affect all the provider’s patients. Findings included:Review of the provider’s policy titled, “Interdisciplinary Group (IDG) Meeting,” updated 11/01/2024, showed in part the IDG was responsible for the following:- Review the status for each patient from the perspective of each discipline;- Revise the patient’s Plan of Care (POC) as appropriate; and- Discuss ways to deal with special issues that arise in individual cases. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 03/20/2025 with a terminal diagnosis of unspecified cirrhosis (chronic liver damage from a variety of causes leading to scarring and liver failure) of the liver. The patient resided in a facility.Review of the document titled, “Interdisciplinary Group (IDG) Meeting,” dated 04/23/2025, showed the following orders:-Skin prep (protective barrier) bilateral heels for skin protection, start date 03/24/2025; and-Left ear apply skin prep BID (two times daily), start date 03/24/2025.The orders failed to specify who and what days the staff would be responsible for the wound care (the patient resided in a facility).Review of the long-term care facility’s document titled, “Order Summary Report,” dated 05/06/2025, showed the following:-Apply skin prep to bilateral heels, posterior heels DTPI (deep tissue pressure injury), float heels, reposition frequently, every shift for wound care/prevention, start date of 03/21/2025; and-There was no order for wound care to the left ear.During an interview on 05/08/2025 at 10:00 AM, the hospice administrator stated that he/she would expect the information for who was responsible for the treatments to be in the order and on the hospice plan of care. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 12/30/2024 with a terminal diagnosis of urinary bladder cancer. The patient had secondary diagnoses of, but not limited to, dementia (decline in mental capacity), and a history of urinary tract infections (UTIs). The patient resided in a memory care unit of a local assisted living facility (ALF).Review of the document titled, “Interdisciplinary Group Meeting,” dated 04/23/2025, showed in part a visit frequency of one time per month for the hospice social worker and chaplain. Review of the document titled, “Long-Term Care/Hospice Coordination of Care Form,” dated 12/30/2024, showed the hospice social worker and chaplain were to visit the patient two to four times per month. During an interview on 05/08/2025 at 10:00 AM, the administrator stated that:- The interdisciplinary group meeting document was considered the patient’s updated plan of care; and- They would expect the coordinated care plan at the facility to reflect the most current visit frequency orders for the medical social worker and chaplain.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure spiritual services were provided to the best of their ability in five of five records reviewed (Records/Patients #1, #2, #3, #4, and #5). This deficient practice has the potential to impact the spiritual counseling needs for all the patients served by the provider. Findings included:Review of the provider’s policy titled, “Scope of Core Services,” updated 11/01/2024, showed in part the following:-Spiritual Care-The spiritual counselor or spiritual caregiver/chaplain may contact community spiritual caregivers if desired by the patient/family unit with documented consent.RECORDS/PATIENTS #1, #2, #3, #4, and #5:Review of the clinical records showed the patients’ had active chaplain visit orders, but failed to have visits provided from 03/31/2025 to 04/21/2025.Review of an email from the chaplain, dated 03/31/2025, showed he/she would no longer be available to make visits to patients effective immediately.Review of an email sent to the social work team, dated 04/08/2025, showed a plan for the social work team to help evaluate the hospice patient’s spiritual needs at least monthly. (The social work team consisted of four social workers.) The note also included a plan for a potential volunteer, who was a retired pastor, that might be able to assist with spiritual care.Review of the current employee roster showed two new chaplains with hire dates of 04/21/2025.During an interview on 05/05/2025 at 2:10 PM, the hospice chief operating officer stated that they had a discussion with the social work team and if anyone had requested spiritual needs or care they should let him/her know and he/she could reach out to the community to find support.”

“Based on policy review and record review, the hospice provider failed to ensure the aide care plan prepared by the registered nurse (RN) was patient specific in five of five aide care plans reviewed (Records/Patients #1, #2, #3, #4, and #5). This deficient practice has the potential to impact all patients receiving aide services. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 04/08/2025 with a terminal diagnosis of prostate cancer. The patient had secondary diagnoses of, but not limited to, urinary retention, osteonecrosis of the jaw (a condition where bone tissue dies due to a lack of blood supply), and diabetes (a group of diseases that results in too much sugar in the blood). The patient resided in his/her own home with the assistance of his/her spouse. Review of the document titled, “Interdisciplinary Group Meeting,” dated 04/23/2025, showed the registered nurse (RN) developed a hospice aide assignment sheet that: - Included interventions that failed to include a frequency of task performance including the monitoring of vital signs, empty foley catheter, oral care, perineal care, skin care, incontinent care, document bowel movements, may trim or file any long or uneven fingernails, shave, nail care, shampoo; and- Failed to include parameters for care for interventions that directed the hospice aide to report abnormal vital signs to the nurse, report patient pain to the nurse, when to provide a bath versus a shower, and report to RN if no bowel movement. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 12/30/2024 with a terminal diagnosis of urinary bladder cancer. The patient had secondary diagnoses of, but not limited to, dementia (decline in mental capacity), and a history of urinary tract infections (UTIs). The patient resided in a memory care unit of a local assisted living facility (ALF).Review of the document titled, “Interdisciplinary Group Meeting,” dated 04/23/2025, showed the registered nurse (RN) developed a hospice aide assignment sheet that: - Included interventions that failed to include a frequency of task performance including the monitoring of vital signs, oral care, may trim or file any long or uneven toenails, perineal care, skin care, incontinent care, document bowel movements, may trim or file any long or uneven fingernails, shampoo; and- Failed to include parameters for care for interventions that directed the hospice aide to report abnormal vital signs to the nurse, report patient pain to the nurse, when to provide a bath versus a shower, and report to RN if no bowel movement. RECORD/PATIENT #5:Review of the clinical record showed the patient admitted to hospice services on 03/07/2025 with a terminal diagnosis of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood). The patient had secondary diagnoses of, but not limited to, atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat), diabetes, and sleep apnea (a disorder characterized by pauses in breathing during sleep). The patient resided in his/her own home with the assistance of his/her spouse. Review of the document titled, “Interdisciplinary Group Meeting,” dated 04/30/2025, showed the registered nurse (RN) developed a hospice aide assignment sheet that: - Included interventions that failed to include a frequency of task performance including the monitoring of vital signs, oral care, may trim or file any long or uneven toenails, perineal care, skin care, incontinent care, document bowel movements, foot care, may trim or file any long or uneven fingernails, shampoo; and- Failed to include parameters for care for interventions that directed the hospice aide to report abnormal vital signs to the nurse, report patient pain to the nurse, when to provide a bath, bed bath, shower, tub bath, or complete bath, what location to shave the patient, and report to RN if no bowel movement. During an interview on 05/08/2025 at 10:00 AM, the administrator and RN coordinator stated that they would expect the aide assignments to have a frequency for the performance of each intervention and parameters/indicators for the provision of interventions that are not every visit. Findings included:Review of the provider’s policy titled, “Personal Care and Homemaker Services,” updated 10/21/2024, showed in part the following;Purpose: All duties (personal care and homemaker services) that a home health aide would otherwise be assigned, will be completed by the hospice nurse or CNA (Certified Nurse Assistant).-Assistance with bathing, shampooing, clipping of nails, applying lotion, oral hygiene, toileting and dressing will be provided, as needed, to patients when the nurse or CNA makes a scheduled visit; and-The hospice nurse or CNA will provide light housekeeping (e.g. changing linens, straightening of bed linens and tidying area to maintain safety for patient). RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 03/20/2025 with a terminal diagnosis of unspecified cirrhosis (chronic liver damage from a variety of causes leading to scarring and liver failure) of the liver. The patient was non-ambulatory, and had a Foley catheter (a sterile tube placed in the bladder to drain urine) at the time of his/her admission to the long-term care facility. Review of the document titled, “Aide Care Plan,” dated 03/20/2025 and printed on 05/05/2025, showed the following:-Elimination- Document bowel movements (BM);-Elimination- Report to RN if no BM (failed to indicate how many days between bowel movements for notification);-Hygiene-Bath- Complete (failed to specify the type of bath to be given and the frequency);-Hygiene-Nail Care (frequency for cleaning, frequency for clipping);-Hygiene-Oral Care;-Hygiene-Perineal Care (failed to indicate the patient has a Foley catheter);-Hygiene-Shampoo (frequency daily-weekly);-Hygiene-Shave (the location to shave was not indicated);-Hygiene-Skin Care;-Safety-Fall Precautions;-Safety-Oxygen Precautions;-Vital Signs-Assess Pain (this is not within the scope of practice for an aide-they can report pain);-Vital Signs-Blood Pressure;-Vital Signs-Other Spo2;-Vital Signs-pulse;-Vital Signs-Report abnormal vital signs to nurse;-Vital Signs-Report patient pain to nurse;-Vital Signs-Respirations;-Vital Signs-Temperature. Review of the document titled, “Interdisciplinary Group (IDG) Meeting,” dated 03/26/2025, showed the patient had the following changes:-The patient developed a wound to the left ear on 03/24/2025;-The patient developed bilateral heel wounds on 03/24/2025; -The patient developed a wound to the buttocks on 03/24/2025; and-The aide care plan failed to include the updates and what the hospice aide should do to the dressing or wound, and failed to address the Foley catheter. Review of the document titled, “IDG Meeting,” dated 04/23/2025, showed the hospice aide interventions failed to include what the aide should do in regards to the Foley catheter, and dressings or wounds (left ear wound, bilateral heel wounds, or the buttock wounds). RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 03/20/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe) and comorbidities of type II (two) diabetes (a chronic disease that results in too much sugar in the blood) and osteoarthritis (a common joint disease that causes pain, stiffness, and loss of mobility). The patient resided at the home with his/her spouse.Review of the document titled, “Interdisciplinary Care Plan,” dated 03/20/2025 and printed on 05/05/2025, showed the following hospice aide interventions that:- Failed to include a frequency of task performance including the monitoring of document bowel movements, incontinent care, bed bath, shower, may trim or file any long or uneven fingernails and toenails, oral care, perineal care, shampoo, shave, skin care, and vital signs ; and- Failed to include parameters for care for interventions that directed the hospice aide to report abnormal vital signs to the nurse, report patient pain to the nurse, when to provide a bed bath versus a shower, and report to RN if no bowel movement. Review of the document titled, “Interdisciplinary group (IDG) Meeting,” dated 04/30/2025, showed the hospice aide reported that he/she offered care on visits, but the patient refused and the [private pay] caregiver provided personal care.Review of the document titled, “Skilled Nursing (SN) Visit,” dated 05/01/2025, showed the supervision note as personal care was given by the aide. (The registered nurse was aware the aide did not provide personal care to the patient).Review of the document titled, “Aide Care Plan,” dated 03/20/2025 and printed 05/05/2025, showed the hospice aide would provide the following personal care interventions:- Incontinent care;- Bed bath;- Shower bath;- May trim or file any long or uneven finger nails;- May trim or file any long or uneven toe nails;- Oral care;- Perineal care;- Shampoo;- Shave; and- Skin care.Observation on 05/06/2025 at 10:05 AM, showed the patient’s private pay caregiver in the home with the patient. Per interview conducted during the observation, the caregiver stated that he/she cared for the patient weekly, from 9:00 AM to 12:00 PM, Tuesday through Friday. He/She gave the patient a shower every other day or more often as needed due to the patient’s “bouts with uncontrollable” diarrhea. The patient’s spouse gave showers if needed due to incontinence. The caregiver stated that the hospice aide usually comes in the afternoon. The patient stated that the hospice aide took his/her vitals and sometimes did his/her nails, but preferred the caregiver to do them.During an interview on 05/08/2025 at 9:35 AM, the administrator stated that the aide should report to the registered nurse the patient’s refusal of services. He/She stated that the supervising nurse should update the aide care plan to address new assignments.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure that the hospice aide provided services as ordered by the registered nurse (RN) in one of five records reviewed (Record/Patient #2). This deficient practice has the potential to affect the delivery of all aide services provided. Findings included:Review of the provider’s policy titled, “Personal Care and Homemaker Services,” updated 10/21/2024, showed in part the following;Purpose: All duties (personal care and homemaker services) that a home health aide would otherwise be assigned, will be completed by the hospice nurse or CNA (certified nurse assistant).-Assistance with bathing, shampooing, clipping of nails, applying lotion, oral hygiene, toileting and dressing will be provided, as needed, to patients when the nurse or CNA makes a scheduled visit; and-The hospice nurse or CNA will provide light housekeeping (e.g. changing linens, straightening of bed linens and tidying area to maintain safety for patient). RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 03/20/2025 with a terminal diagnosis of unspecified cirrhosis (chronic liver damage from a variety of causes leading to scarring and liver failure) of the liver. The patient was non-ambulatory and had a Foley catheter (a sterile tube placed in the bladder to drain urine) at the time of his/her admission to the long-term care facility. Review of the document titled, “Aide Care Plan,” with a start date of 03/20/2025, showed the aide frequency was three times per week. There were 19 tasks on the aide care plan and six of the tasks had a high degree of variation with completion and they are listed below.Review of the document titled, “Aide Visit Notes,” dated from 03/25/2025 to 05/02/2025 showed the following:-Oral care; the aide failed to document that oral care was provided on any of the visits in this date range;-Bath-complete; the aide documented a shower was provided on 03/25/2025, 04/01/2025, and 04/25/2025; a partial bed bath or complete bed bath was provided on 03/28/2025, 04/04/2025, 04/08/2025, 04/11/2025, 04/15/2025, 04/22/2025, 04/29/2025, and 05/02/2025; and the aide failed to document that a bath was provided on 03/26/2025, 04/02/2025, 04/09/2025, 04/16/2025, 04/23/2025, and 04/30/2025;-Elimination-Document bowel movements (BM); the aide failed to document a BM on 03/28/2025, 04/01/2025, 04/02/2025, 04/09/2025, 04/22/2025, and 04/29/2025;-Shave; the aide documented one offer to shave the patient on 04/09/2025 and the patient declined; there was no other documentation found in the record regarding shaving the patient;-Perineal care; the aide failed to document that perineal care was provided on 03/26/2025, 04/02/2025, 04/16/2025, 04/23/2025, and 04/30/2025; and -Nail care; the aide failed to document that nail care was provided on 03/25/2025, 03/28/2025, 04/01/2025, 04/02/2025, 04/04/2025, 04/08/2025, 04/11/2025, 04/15/2025, 04/22/2025, 04/25/2025, 04/29/2025, and 05/02/2025.Per interview conducted during the observation of vital sign assessment on 05/06/2025 at 9:10 AM, the aide stated that the care for this patient was to give a bed bath on Tuesday and Friday and to provide perineal care and nail care on Wednesday.During an interview on 05/08/2025 at 10:25 AM, the hospice administrator stated that the registered nurse should ensure the (aide) care plan is being followed and the tasks on the care plan are being followed.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure the hospice aide reported patient changes related to the plan of care in three of five full records reviewed (Records/Patients #1, #3, and #5). This deficient practice has the potential to affect the provision and oversight of hospice aide services for all of the provider’s patients. Findings included: Review of the provider’s policy titled, “CNA (certified nursing assistant) Visit and Electronic Documentation,” dated 10/15/2024, showed that each visit with a patient/family requires accurate information about the visit. This information should include information provided to the primary nurse. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 04/08/2025 with a terminal diagnosis of prostate cancer. The patient had secondary diagnoses of, but not limited to, urinary retention, osteonecrosis of the jaw (a condition where bone tissue dies due to a lack of blood supply), and diabetes (a group of diseases that results in too much sugar in the blood). The patient resided in his/her own home with the assistance of his/her spouse. Review of the document titled, “Hospice Plan of Care,” dated 04/08/2025, showed in part the hospice aide assignment included interventions for the aide to:- Assess/monitor pain, bowel movements (BM), and vital signs;- Observe fall precautions; - Provide incontinent care, a bath, nail care, trimming or filing of any long or uneven fingernails, nail care, oral care, perineal care, shampoo, shave, skin care, and empty Foley catheter (a sterile tube placed in the bladder to drain urine); and- Report patient pain, if no BM, and abnormal vital signs to the nurse. Review of the hospice aide documentation for the dates of 04/10/2025, 04/17/20245, 04/24/2025, and 05/01/2025, showed the visit notes failed to contain documentation of registered nurse (RN) notification that: - Incontinent care, foot care, nail trimming, perineal care, shampoo, and skin care were not provided during the aide visit as the spouse provides the care; and- The patient’s pain, BM, or abnormal vital signs. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 12/30/2024 with a terminal diagnosis of urinary bladder cancer. The patient had secondary diagnoses of, but not limited to, dementia (decline in mental capacity), and a history of urinary tract infections (UTIs). The patient resided in a memory care unit of a local assisted living facility (ALF). Review of the document titled, “Interdisciplinary Group Meeting,” dated 04/23/2025, showed in part the hospice aide assignment included interventions for the aide to:- Assess/monitor pain, bowel movements, and vital signs;- Observe oxygen precautions; - Provide incontinent care, a complete/shower/bath, foot care, oral care, perineal care, shampoo, skin care, May trim or file any long or uneven finger or toenails; and- Report the patient’s pain and abnormal vital signs to the nurse. Review of the hospice aide documentation for the dates of:- 04/23/2025, 04/24/2025, 04/28/2025, 04/30/2025, and 05/01/2025, showed the visit notes failed to contain documentation of RN notification that: * The patient’s pain, abnormal vital signs, or bowel movements; and * The performance of a bath or a complete bath; and- On 04/23/2025 and 04/24/2025 the trimming or filing of any long or uneven finger or toenails. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 03/07/2025 with a terminal diagnosis of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood). The patient had secondary diagnoses of, but not limited to, atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat), diabetes, and sleep apnea (a disorder characterized by pauses in breathing during sleep). The patient resided in his/her own home with the assistance of his/her spouse. Review of the document titled, “Hospice Plan of Care,” dated 03/07/2025, showed in part the hospice aide assignment included interventions for the aide to:- Assess/monitor pain, bowel movements, and vital signs;- Observe fall and oxygen precautions; - Provide incontinent care, a bed/complete/partial/shower/shower chair/tub bath, nail care, oral care, perineal care, shampoo, shave, skin care; and- Report patient pain, if no BM, and abnormal vital signs to the nurse. Review of the hospice aide documentation for the dates of 04/15/2025, 04/22/2025, 04/25/2025, 04/29/2025, and 05/02/2025, showed the visit notes failed to contain documentation of RN notification that:- The patient’s pain or bowel movements; - Provision of incontinent care, foot care, nail trimming, perineal care, shampoo, and skin care; and- The patient’s pain, BM, or abnormal vital signs. During an interview on 05/08/2025 at 10:00 AM, the administrator and RN coordinator stated that they would expect the aide to notify the RN when interventions are not provided during the visit, as well as, when the assignment includes interventions for RN notification regarding pain and bowel movements.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure the registered nurse (RN) was supervising the provision of care as ordered on the aide care plan in two of five records reviewed (Records/Patients #2 and #4). This deficient practice has the potential to affect all the patients receiving aide services. Findings included:Review of the provider’s policy titled, “Nursing Services Scope of Practice,” updated 10/15/2024, showed the registered nurse (RN) shall make on-site visits at least every 14 days and document in the electronic medical record that the hospice aide (CNA (certified nurse aide)) is routinely providing services in accordance with the plan of care.RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 03/20/2025 with a terminal diagnosis of unspecified cirrhosis (chronic liver damage from a variety of causes leading to scarring and liver failure) of the liver. The patient was non-ambulatory and had a Foley catheter (a sterile tube placed in the bladder to drain urine) at the time of his/her admission to the long-term care facility.Review of the document titled, “Aide Care Plan” with a start date of 03/20/2025 showed the aide frequency was three times per week. There were 19 tasks on the aide care plan and six of the tasks had a high degree of variation with completion and they are listed below.Review of the document titled, “Aide Visit Notes,” dated from 03/25/2025 to 05/02/2025 showed the following:- Oral care; the aide failed to document that oral care was provided on any of the visits in this date range;- Bath-complete; the aide documented a shower was provided on 03/25/2025, 04/01/2025, and 04/25/2025; a partial bed bath or complete bed bath was provided on 03/28/2025, 04/04/2025, 04/08,/2025 04/11/2025, 04/15/2025, 04/22/2025, 04/29/2025, and 05/02/2025; and the aide failed to document that a bath was provided on 03/26/2025, 04/02/2025, 04/09/2025, 04/16/2025, 04/23/2025, and 04/30/2025;- Elimination-Document bowel movements (BM); the aide failed to document a BM on 03/28/2025, 04/01/2025, 04/02/2025, 04/09/2025, 04/22/2025, and 04/29/2025;- Shave; the aide documented one offer to shave the patient on 04/09/2025 and the patient declined, there was no other documentation found in the record regarding shaving the patient;- Perineal care; the aide failed to document that perineal care was provided on 03/26/2025, 04/02/2025, 04/16/2025, 04/23/2025, and 04/30/2025; and - Nail care; the aide failed to document that nail care was provided on 03/25/2025, 03/28/2025, 04/01/2025, 04/02/2025, 04/04/2025, 04/08/2025, 04/11/2025, 04/15/2025, 04/22/2025, 04/25/2025, 04/29/2025, and 05/02/2025.Review of the document titled, “Skilled Nursing Visit Note,” dated 04/03/2025, showed an aide supervision note was included; the question, “hospice aide’s name”, the name of the aide was incorrect (the same aide provided all 17 aide visits to the patient); the question, “aide follows plan of care” was answered, yes. (There were tasks that were not being completed.) There was no explanation for the incomplete tasks.Review of the document titled, “Skilled Nursing Visit Note,” dated 05/01/2025, showed an aide supervision note was included; the question “hospice aide’s name”, the correct aide’s name was there with another aide’s name also typed in (the same aide provided all 17 aide visits to the patient); the question, “aide follows plan of care” was answered, yes. (There were tasks that were not being completed.) There was no explanation for the incomplete tasks. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 03/20/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe) and comorbidities of type II (two) diabetes (a chronic disease that results in too much sugar in the blood) and osteoarthritis (a common joint disease that causes pain, stiffness, and loss of mobility). The patient resided at the home with his/her spouse.Review of the document titled, “Hospice Plan of Care,” dated 03/20/2025, showed in part the hospice aide assignment included interventions for the aide to:- Document bowel movements (BM);- Report patient pain, if no BM, and abnormal vital signs to the nurse;- Provide incontinent care, a bed bath, shower, trimming or filing of any long or uneven fingernails and toenails, nail care, oral care, perineal care, shampoo, shave, skin care;- Observe fall and oxygen precautions; and- Assess pain and vital signs.Review of the documents titled, “Aide Visit,” dated 03/25/2025, 03/26/2025, 03/28/2025, and 04/01/2025, failed to contain documentation of RN notification of the following: - The patient refused incontinent care, bed bath, shower, nail trimming or filing, nail care, oral care, perineal care, shampoo, shave, and skin care; and- The patient’s pain, bowel movements, and abnormal vital signs. Review of the document titled, “RN (registered nurse) Comprehensive Assessment,” dated 04/03/2025, showed the following hospice aide supervision documentation:- Showed that the aide: * Followed the plan of care; * Had adequate documentation; and * Provided personal care.- Failed to address the failure of the aide to: * Provide the interventions included in the plan of care; and * Report to the RN any interventions that were not performed, the patient’s pain, bowel movements, or abnormal vital signs.”

“Based on policy review, record review, and interview the hospice provider failed to ensure the discharge summary that was sent to the attending physician included a summary of the patient’s stay including treatments, symptoms and pain management, a current plan of care, and the latest physician orders in two of four focused records reviewed (Records/Patients #7 and #8). This deficient practice has the potential to impact the continuity of care for all the patients who are live discharges from the provider. Findings included:Review of the provider’s policy titled, “Discharge, Transfer, and Revocation Summary Documentation,” updated 10/18/2024, showed in part the discharge summary contains a current summary of the patients condition. The provider’s policy failed to include all of the required elements. RECORD/PATIENT #7:Review of the clinical record showed a discharge summary was completed for the patient. The summary was sent to the physician. The summary failed to contain a summary of the patient’s stay to include treatments, symptoms and pain management, a current plan of care, and the latest physician orders. RECORD/PATIENT #8:Review of the clinical record showed a discharge summary was completed for the patient. The summary was sent to the physician. The summary failed to contain a summary of the patient’s stay to include treatments, symptoms and pain management, a current plan of care, and the latest physician orders. During an interview on 05/08/2025 at 10:00 AM, the office manager stated that the information requested was not in the patient record and had not been sent to the physician.”

“Based on policy review, record review, home visit observation, and interview, the hospice provider failed to ensure the Long-Term Care/Hospice Coordination of Care Form was updated when changes in care occurred in one of one facility patient record reviewed (Record/Patient #2). This deficient practice has the potential to affect the care and services for all hospice patients receiving care in a facility. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 12/30/2024 with a terminal diagnosis of urinary bladder cancer. The patient had secondary diagnoses of, but not limited to, dementia (decline in mental capacity), and a history of urinary tract infections (UTIs). The patient resided in a memory care unit of a local assisted living facility (ALF).Review of the document titled, “Interdisciplinary Group Meeting,” dated 04/23/2025, showed in part a visit frequency of one time per month for the hospice social worker and chaplain. Review of the document titled, “Long-Term Care/Hospice Coordination of Care Form,” dated 12/30/2024, showed the hospice social worker and chaplain were to visit the patient two to four times per month. During an interview on 05/08/2025 at 10:00 AM, the administrator stated that:- The interdisciplinary group meeting document was considered the patient’s updated plan of care; and- They would expect the coordinated care plan at the facility to reflect the most current visit frequency orders for the medical social worker and chaplain. Findings included:Review of the provider’s policy titled, “Nursing Coordination of Care Task Plan Documentation,” updated October 21, 2024, showed in part the following:-Note start date of wound care and site/treatment; and-Update form as needed. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 03/20/2025 with a terminal diagnosis of unspecified cirrhosis (chronic liver damage from a variety of causes leading to scarring and liver failure) of the liver. The patient resided in a facility.Review of the Interdisciplinary Group (IDG) Meeting note dated 03/26/2025 showed the patient had the following changes: on 03/24/25, the patient developed wounds to the left ear, bilateral heels, and buttocks.During a home visit observation, on 05/06/2025 at 8:35 AM, the facility hospice binder was reviewed, and the Long-Term Care/Hospice Coordination of Care Form was examined. The nurse section, aide sections, social work section, chaplain section, and Foley catheter were completed on the form. The sections for wound care were blank. During an interview on 05/08/2025 at 10:00 AM, the hospice administrator stated that he/she would expect the wounds to be on the (Long-Term Care/Hospice Coordination of Care) form.”