Good Shepherd Hospice of Mid-America, Inc.

“Based on policy review, employee file review, and interview, the hospice provider failed to ensure all employees received emergency preparedness training in one of five employee files reviewed (E-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 policy titled, “Competency Assessment and Orientation,” revised 06/01/2020, showed in part:- All newly hired employees participate in an orientation program and competency review prior to providing patient care; and- Patient care employees received orientation appropriate to their job function including emergency preparedness. E-4:Review of E-4’s employee file showed the employee’s date of hire was 09/10/2025. The employee file failed to include documentation of orientation/training for emergency preparedness.During an interview on 11/04/2025 at 1:40 PM, the hospice administrator stated that he/she could not confirm that E-4 had emergency preparedness training.”

“Based on policy review, record review, and interview, the provider failed to ensure the comprehensive assessment identified all physical needs, including wound assessment, for one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Applicable Standards: Wound Care and Skin Integrity Assessments,” dated 06/05/2019, showed in part the following: - Skin inspections will be completed on admission and during each skilled nursing visit;- The presence of skin breakdown/abnormal skin appearance, i.e. abrasion, blister, bruising - due to pressure, burn denuded (made bare), erythema (redness), hematoma (accumulation of blood in the tissue), laceration (a tear or cut in the flesh), rash, skin tear and wound will be documented in the patient’s medical record upon admission and during the skilled nurse visits; and- Upon identification of a wound, a full wound assessment, including it’s location, size and description of the tissue involved, will be completed. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 10/17/2025 with a terminal diagnosis of osteomyelitis (inflammation or infection in the bone). The patient resided at home with his/her spouse who was also the primary caregiver. Review of the start of care nursing visit note, dated 10/17/2025, showed in part:- Osteomyelitis was the primary diagnosis;- History of motor vehicle accident in 1995, resulting in incomplete cervical (related to the neck) level spinal cord injury, resulting in quadriplegia (paralysis of the arms and legs);- Recent hospitalization for baclofen pump (a surgically implanted pump that delivers medication to treat spasticity or chronic pain) failure with associated cerebrospinal fluid (fluid that cushions the brain and spinal cord) leak, removal of pump causing worsening pain and reduced wound healing;- Stage four pressure injury (a full thickness loss of the skin with extensive destruction, exposing muscle, bone, tendon, or ligaments) to right hip appeared beefy red with tunneling (current dressing per husband’s orders included Dakin’s wet-to dry dressing covered with sacral border foam and changed daily); - The nurses note showed the “wound will be measured at next nursing assessment”; and- The nurse failed to document wound measurements. Review of the nursing visit note, dated 10/18/2025, showed the nurse, “changed dressing to wound on right hip per orders, without difficulty.” The documentation failed to include skin appearance, size or measurements of the wound. Review of the nursing visit note, dated 10/19/2025, for an as needed (PRN) nurse visit, showed discussion of pain and pain medication, but failed to include an assessment of the right hip wound including measurements or appearance. Review of the nursing visit note, dated 10/20/2025, showed in part the following:- One stage four pressure ulcer;- Wound on right hip measuring 3.4 centimeters (cm) x 1 cm (this was the first wound measurement recorded in patient’s clinical record);- Wound was beefy red with tunneling; and- Treatment “done as ordered”. Review of the nursing visit note, dated 10/24/2025, showed “dressing to right hip changed”. The documentation failed to include the wound appearance or measurements. Review of the nursing visit note, dated 10/27/2025, showed “has wound on right hip, treatment done as ordered.” The documentation failed to include the wound appearance or measurements. Review of the nursing visit note, dated 10/31/2025, showed “dressing change is completed per orders, wound cleansed with Dakin’s solution, Dakin’s soaked gauze applied to wound bed, followed by a wet-to dry dressing, and covered with a bordered foam dressing. Dressing to be changed daily”. The documentation failed to include the wound appearance or measurements. Review of the nursing visit note, dated 11/03/2025, showed in part:- Wound care completed at this visit;- Wound measurements 3.4 cm x 2.7 cm x 1 cm; and- Wound bed without erythema or edema (swelling of tissues).During an interview on 11/06/2025, the executive director (supervised the administrator) stated that when a patient had a stage four pressure sore on admission, the nurses were expected to do daily visits and daily dressing changes. The nurses should have been doing daily visits, assessing the wound daily, including recording the appearance and measurements of the wound. He/She stated that they have provided ongoing training of this issue for staff.”

“Based on policy review, record review, and interview, the hospice provider failed to maintain an accurate medication profile in two of four patients where a home visit was completed (Records/Patients #1 and #2). This deficient practice has the potential to affect the accuracy of medication administration for all patients served by the provider. Findings Included:Review of the policy titled, “Hospice Medications” revised 07/11/2024 showed in part:All skilled nurses will reconcile medications for all patients during a skilled nurse visit: andMedications will be reviewed during the Interdisciplinary Team (IDT) meeting with the hospice physician. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 06/13/2024 with a terminal diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), with additional diagnosis which included hypertension (abnormally elevated blood pressure), and diabetes (a chronic disease that affects how the body uses sugar for energy). The patient resided in a SNF. Review of the facility’s Medication Administration Record (MAR) dated 11/06/2025, showed an active order (08/13/2025) for clonazepam 0.5 mg tablet (an anti- anxiety medication) two times each day. Review of the Plan of Care dated 09/15/2025 failed to show clonazepam 0.5 mg tablet two times each day as part of the patient’s current medication regimen. During an Interview on 11/06/2025 at 9:30 AM the Registered Nurse (RN) coordinator stated she work expect staff to follow policy with regard to medication reconciliation. The patient’s medication should have be reconciled since the patient has weekly skilled nurse visits. Findings included:Review of the provider’s policy titled, “Medication-Management,” dated 07/14/2014, showed in part that a drug profile was maintained for every patient that included a list of the current medication orders and was reviewed and updated with each medication change. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 08/14/2025 with a terminal diagnosis of Alzheimer’s disease (a disease marked by progressive loss of mental capacity). The patient resided in a skilled nursing facility (SNF). Review of the hospice provider’s medication list dated 11/04/2025 showed the patient was currently taking the following medications:- Levothyroxine (hormone used to treat an underactive thyroid);- Melatonin (used to regulate the sleep-wake cycle);- Multivitamin (dietary supplement); and- Potassium Chloride (potassium supplement).The medication list failed to contain the following medications:- Tylenol (used to treat pain or fever) 325 milligrams (mg) two tablets by mouth two times daily for generalized pain; and- Omeprazole (decreases the amount of acid produced in the stomach) 20 mg one tablet by mouth daily.Review of the SNF’s Order Summary Report dated 11/05/2025 showed the following:- Levothyroxine, melatonin, multivitamin, and potassium chloride were not listed (patient was not taking); and - Tylenol 325 mg two tablets by mouth two times daily for generalized pain with a start date of 10/11/2023 was listed as a current medication; and- Omeprazole 20 mg one tablet by mouth daily with a start date of 09/15/2025 was listed as a current medication.”

“Based on policy review, record review, home visit observation, and interview, the hospice provider failed to ensure that each patient received an individualized initial or revised plan of care (POC) in two of five full records reviewed (Records/Patients #1 and #2). This deficient practice has the potential to affect all patients served by the provider. Findings included:Review of the provider’s policy titled, “Plan of Care” revised 10/2011 showed, in part:- The patient’s plan of care specifies the care and services necessary to meet the needs of the patient/ caregivers identified in the initial, comprehensive and updated assessment of the patient. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 06/13/2024 with a terminal diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), with additional diagnosis which included hypertension (abnormally elevated blood pressure), and diabetes (a chronic disease that affects how the body uses sugar for energy). The patient resided in a skilled nursing facility. Observation on 11/04/2025 at 12:45 PM showed the patient sitting in a wheelchair with a protective foam helmet in place, and with protective pads worn on both hips, elbows, and knees.Review of the Plan of Care (POC) dated 09/15/2025, failed to include knee pads to be wore on each knee as part of the patient’s fall prevention interventions.During an interview on 11/04/2025 at 12:45 PM, the Certified Nurse Aide (CNA) stated the patient, “always wore knee pads” in addition to hip pads, elbow pads, and protective helmet due to being at a high risk for falls. During an interview on 11/06/2025 at 09:30 AM the Registered Nurse (RN) coordinator stated the patient’s POC should reflect all care needs and services that are required for the patient. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 08/14/2025 with a terminal diagnosis of Alzheimer’s disease (a disease marked by progressive loss of mental capacity). The patient resided in a skilled nursing facility (SNF).Review of the skilled nurse (SN) visit note dated 10/16/2025 showed the SN documented the patient had a change in condition when the SNF staff reported that the patient had a skin tear to the left lower extremity. The SNF’s Order Summary Report dated 11/05/2025 contained an order dated 10/15/2025 for the SNF nurse to clean and dress the wound every day shift every Monday, Wednesday and Friday. The hospice clinical record failed to include the wound care orders, and the POC dated 10/22/2025 failed to include the orders, and failed to include an update to the impaired skin integrity goal and intervention.Review of the SN visit note dated 10/21/2025 showed the SN documented the patient had a change in condition when the SN requested medication for edema (swelling) to the patient’s lower extremities. The SN obtained an order for new medications and an interim order was written. The POC dated 10/22/2025 failed to include the medication orders and no new goals or interventions were added related to edema.Further review of the POC dated 10/22/2025 showed a care plan, goal, and intervention for insomnia (difficulty falling or staying asleep). The clinical record documentation showed the patient slept 20-22 hours per day. The POC showed a care plan, goal, and intervention for anticoagulant (medication to thin the blood) therapy. The patient was not taking anticoagulant medications.”

“Based on policy review, record review, home visit observation, and interview, the hospice provider failed to ensure the registered nurse (RN) updated the aide care plan with changes in the patient’s condition in one of four full records reviewed with aide services (Record/Patient #1). This deficient practice has the potential to affect all the provider’s patients with aide services. Findings included:Review of the provider’s policy titled, “Hospice Aide/Homemakers Assignments and Duties,” revised 01/15/2020, showed in part, the hospice aide follows written patient care instructions in providing care to assigned patients.RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 08/14/2025 with a terminal diagnosis of Alzheimer’s disease (a disease marked by progressive loss of mental capacity). The patient resided in a skilled nursing facility (SNF).Review of the SNF’s order summary report dated 11/05/2025, showed an active order, dated 10/15/2025, for wound care to a skin tear on the left lower extremity every day shift on Monday, Wednesday and Friday.Review of the provider’s aide care plan report effective 08/15/2025, showed the aide care plan failed to be updated to include instructions for the aide related to the wound or wound dressing to the patient’s left lower extremity.During an interview on 11/06/2025 at 9:50 AM, the hospice registered nurse coordinator (RNC) stated that he/she would expect the aide care plan to be updated.”

“Based on policy review, observation, and interview, the hospice provider failed to ensure the hospice multiple locations maintained the same days and hours of operation as the parent hospice provider location in two of four multiple locations visited (multiple location A and B). This deficient practice has the potential to affect all patients served by the provider. Multiple Location B: The current census of multiple location B was 21 current patients.Observation on 11/05/2025 at 11:10 AM, showed the multiple location occupied a section of a multi-business building. The outside door to multiple location B’s door was locked. The interior door from the joint lobby was also locked. There were no staff observed in the building, and the interior of the provider’s office had no interior lighting. The exterior door also had a combination pad lock on the door handle. The stenciled lettering on the interior door identified the provider by name with office hours listed as: “Monday to Friday 8:00 A.M. to 5 P.M”. The door also listed,” For assistance 24/7 please call xxx-xxx-xxxx (the telephone number of the provider’s parent office). Review of the provider’s policy titled, “Applicable Standards Alternative Delivery Site” dated 04/13/2020 showed in part: - The hospice administrator will be responsible for alternate delivery sites and will be responsible to ensure implantation of agency policies and procedures at the parent and alternate delivery site (s).- - The administrator or alternate administrator will continually monitor and manage all services provided at the parent alternate delivery site (s). Multiple Location A: The census for multiple location A was 5 current patients.Observation on 11/04/2025 at 2:00 PM, showed the multiple location occupied a section of a multi- business building. The door to multiple location A’s door was locked. There were no staff observed in the building, and the interior of the provider’s office had no interior lighting. The glass front door also had a combination pad lock in the door handle. The stenciled lettering on the front door glass identified the provider by name with office hours listed as: “Monday to Friday 8:00 A.M. to 5 P.M”. The door also listed,” For assistance 24/7 please call xxx-xxx-xxxx (the telephone number of the provider’s parent office).During an interview on 11/04/2025 at 2:05 PM, business owner #1 stated their business had been at that location for 9 years. The provider had rented the section of the building next door for “about a year”. Business owner #1 stated initially the provider was at the location “every day” but now is “in and out”. Business owner #1 stated” staff aren’t there very long, and “never all day”. Business owner #1 stated they sometimes accept delivery parcels on the provider’s behalf in the provider’s absence.During an interview on 11/04/2025 at 2:11 PM, business owner #2 stated their business shared the same building. Business owner #2 also stated the provider was, “hit and miss being there”, and the staff are, “never there a full day” when describing the hospice provider’s staffing of the office location. During an interview on 11/06/2025 at 9:50 AM, the administrator and executive director stated there had been “issues” with staffing some of the locations due to personnel reasons. Findings included: Review of the provider’s policy titled, “Applicable Standards Alternative Delivery Site,” dated 04/13/2020, showed in part: - The hospice administrator will be responsible for alternate delivery sites and will be responsible to ensure implantation of agency policies and procedures at the parent and alternate delivery site(s).- - The administrator or alternate administrator will continually monitor and manage all services provided at the parent alternate delivery site(s). Multiple Location A: The census for multiple location A was (5) current patients.Observation on 11/04/2025 at 2:00 PM, showed the multiple location occupied a section of a multi- business building. The door to multiple location A was locked. There were no staff observed in the building, and the interior of the provider’s office had no interior lighting. The glass front door also had a combination pad lock in the door handle. The stenciled lettering on the front door glass identified the provider by name with office hours listed as: “Monday to Friday 8:00 A.M. to 5 P.M”. The door also listed,” For assistance 24/7 please call xxx-xxx-xxxx (the telephone number of the provider’s parent office).During an interview on 11/04/2025 at 2:05 PM, business owner #1 stated their business had been at that location for 9 years. The provider had rented the section of the building next door for “about a year”. Business owner #1 stated initially the provider was at the location “every day” but now is “in and out”. Business owner #1 stated” staff aren’t there very long, and “never all day”. Business owner #1 stated they sometimes accept delivery parcels on the provider’s behalf in the provider’s absence.During an interview on 11/04/2025 at 2:11 PM, business owner #2 stated their business shared the same building. Business owner #2 also stated the provider was, “hit and miss being there”, and the staff are, “never there a full day” when describing the hospice provider’s staffing of the office location. Multiple Location B: The census of multiple location B was 21 current patients.Observation on 11/05/2025 at 11:10 AM, showed the multiple location occupied a section of a multi-business building. The outside door to multiple location B’s door was locked. The interior door from the joint lobby was also locked. There were no staff observed in the building, and the interior of the provider’s office had no interior lighting. The exterior door also had a combination pad lock on the door handle. The stenciled lettering on the interior door identified the provider by name with office hours listed as: “Monday to Friday 8:00 A.M. to 5 P.M”. The door also listed,” For assistance 24/7 please call xxx-xxx-xxxx (the telephone number of the provider’s parent office).During an interview on 11/06/2025 at 9:50 AM, the administrator and executive director stated there had been “issues” with staffing some of the locations due to personnel reasons.”

“Based on policy review, record review, observation and interview, the hospice provider failed to ensure that the coordination of care form, used to provide coordination of care between the hospice provider and the skilled nursing facility (SNF), was filled out in one of four home visits in a facility (Record/Patient #1). This deficient practice has the potential to affect the coordination of care for all patients that reside in a facility. Findings included:Review of the provider’s policy titled, “Hospice Care for Nursing Facility Residents-Coordination of Care,” dated 06/01/2020, showed, in part, that the hospice ensures that mechanisms are in place to provide for coordination of all hospice services provided to patients residing in facilities.RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 08/14/2025 with a terminal diagnosis of Alzheimer’s disease (a disease marked by progressive loss of mental capacity). The patient resided in a skilled nursing facility (SNF).Review of the provider’s coordination of care binder at the SNF on 11/05/2025 showed a hospice coordination of care form was in the binder. The form was blank, there was nothing filled out for the patient’s name, what disciplines were visiting the patient and what days the staff would visit, the treatment section was blank, and there were no signatures to indicate coordination on the form.Per interview conducted during observation on 11/05/2025 at 9:30 AM, the hospice chaplain looked through the coordination binder and reviewed the coordination of care form and agreed the form was blank, nothing was filled out, and there was no other coordination of care form in the binder.During an interview 11/05/2025 at 9:45 AM with the facility aide that provides care to this patient, when asked when the hospice aide bathes the patient, he/she stated that he/she worked the day shift, Monday through Friday, and the hospice aide comes on Monday and Friday. The hospice clinical record showed the hospice aide provided visits on Wednesday and Friday.”

“Based on policy review, record review, observation and interview, the hospice provider failed to ensure the most recent hospice plan of care (POC), and the physician certification and recertification of the terminal illness form was in the skilled nursing facility’s (SNF) coordination binder in one of four home visits conducted (Record/Patient #1). This deficient practice has the potential to affect the coordination of care for all patients who reside in a SNF. Findings included:Review of the provider’s policy titled, “Hospice Care for Nursing Facility Residents-Coordination of Care,” dated 06/01/2020, showed the most recent POC and the physician certification and recertification of the terminal illness form would be provided to facilities to ensure coordination of all hospice services.RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 08/14/2025 with a terminal diagnosis of Alzheimer’s disease (a disease marked by progressive loss of mental capacity). The patient resided in a SNF.Review of the provider’s coordination of care binder at the SNF on 11/05/2025 showed the most recent POC, and the physician certification and recertification of the terminal illness form were not present in the binder. The POC in the binder was dated 09/24/2025.Per interview conducted during observation on 11/05/2025 at 9:30 AM, the hospice chaplain looked through the coordination binder for the missing POC and certification of terminal illness form and agreed that the information was missing.”

“Based on policy review, record review and interview, the provider failed to ensure orientation was provided to the staff of skilled nursing facilities (SNF) where hospice patients received care. This deficient practice has the potential to affect all of the provider’s patients residing in facilities. Findings included: Review of the provider’s policy titled, “Written Agreements,” dated December 2009, showed the hospice provider provides basic orientation and ongoing training to agencies and providers contracted to provide direct patient care. Review of the provider’s training manual titled “Nursing Facility Orientation Book,” used to orient SNF staff where hospice patients received care, showed an undated letter in the front of the manual, with outdated names for the Executive Director and Assistant Director, that showed a list of offered trainings to the facility. No documentation was included for what facilities were offered training, when training was offered, or if facilities accepted or declined the offered training.During an interview on 11/04/2025 at 11:50 AM, the executive director (supervised the administrator) stated the provider had not completed any tracking for the orientation trainings that were offered to the SNFs in the past year. He/She stated that the expectation was for them to take the training materials along with the updated letter in the front of the training manual every time they go into a skilled nursing facility and have the facility staff sign to either accept or decline the training. They should have put this behind their contracts in each facility’s file to make sure this was offered at least annually.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure that the nursing needs of the patient were met, when the provider failed to ensure the patient received; nursing visits from a RN (registered nurse) to reassess the patients decline in condition, wound assessments and wound care three times per week by a skilled nurse, effective pain management for uncontrolled pain, and failed to provide prescription pain medications as ordered by the physician in a timely manner in, but not limited to, one of four records reviewed (Record/Patient #4). This deficient practice has the potential to adversely affect the provision of care to all patients served by the provider. Findings included: Review of the providers policy titled, “Initial and Comprehensive Assessment of the Patient,” revised 10/26/2022, showed, in part: -The hospice interdisciplinary team conducts and documents a patient-specific comprehensive assessment that identifies the patients need for hospice care, including medical, nursing, psychosocial, emotional and spiritual care; -Each member of the interdisciplinary team provides input into the comprehensive assessment within the scope of his/her practice and in accordance with the needs and desires of the patient/family; - Discipline-specific assessment tools obtain accurate and timely information that guide decisions for the development of the patients plan of care; and - The hospices assessment and reassessment tools contain data elements that allow for the measurement of outcomes. RECORD/PATIENT #4: Review of the clinical record, showed, in part: - The patient was admitted to hospice on 01/10/2024. The patient was previously on hospice and had been discharged to receive IV (intravenous) ABT (antibiotics administered through a peripheral vein) for an infection from cellulitis (a bacterial skin infection that causes redness, swelling, and pain) in BLE (bilateral lower extremities); - The patient had a primary hospice diagnosis of malignant neoplasm of right kidney (cancer in the right kidney); - Other diagnoses included, in part; secondary malignant neoplasm of unspecified lung (lung cancer), neoplasm related pain (pain from cancer), peripheral vascular disease (narrowing or blockage of blood vessels from a buildup of plaque), venous insufficiency (a condition in which the veins have problems sending blood from the legs back to the heart), type 2 diabetes mellitus (a disease that results in too much sugar in the blood) with diabetic chronic kidney disease (kidney damage caused by diabetes), emphysema (a type of lung disease that causes shortness of breath), sleep apnea (a condition in which your breathing stops and restarts many times while you sleep), chronic respiratory failure with hypoxia (a condition in which the respiratory system cannot adequately provide oxygen to the body), cellulitis of right lower limb (leg), and cellulitis of left lower limb; and - The patient resided at home with his/her spouse. Review of the hospice IDG (interdisciplinary group) comprehensive assessment and plan of care update report, dated 01/05/2024 to 03/04/2024, showed, in part: - The SOC (start of care) date was 01/05/2024 (the clinical record showed that the patient did not receive an admission visit from the registered nurse until 01/10/2024. The only information/record provided for the visit on 01/10/2024 was a late entry narrative note that was documented by the registered nurse on 01/18/2024); - Lymphedema treatment orders were listed in the medication orders section with a start date of 12/29/2023. The treatment instructions showed, soak BLE in warm water and cleanse, gently rub dry, apply TAO (triple antibiotic ointment) and A&D ointment (used as a skin protectant) from knee to bottoms of feet, rap RLE (right lower extremity) with purple compression wrap, wrap LLE (left lower extremity) with green rap, and change 3 (three) times per week; - Chlorhexidine Gluconate 4% (antiseptic agent that works by killing or preventing the growth of bacteria on the skin) topical liquid scrub to BLE was listed in the medication orders section with a start date of 01/10/2024. The treatment instructions showed, soak and scrub BLE three (3) times per week prior to placing bilayer compression wraps (applies compression to reduce swelling) for bacterial control; - SN (skilled nurse) visit frequency of 2 (two) times per week with 4 (four) PRN (as needed) visits for pain and symptom management. (The patient had lymphedema treatment orders for dressing changes 3 times per week.) The RN (registered nurse) that admitted the patient on 01/10/2024 documented a late entry narrative note, on 01/18/2024, for the SOC visit. The late entry narrative note showed that the RN educated the hospice aide to perform the lymphedema treatment dressing changes and that the aide was able to return demonstration. (The clinical record failed to show an order from the physician for the hospice aid to perform the dressing changes and failed to show documentation of the SN visits when the education was provided); - Interventions for impaired skin integrity included, SN to assess and monitor for s/s (signs and symptoms) of skin breakdown and SN to provide education on prevention of skin breakdown; - Interventions for impaired physical mobility status/risk for impaired skin integrity included SN to educate on effective turning and repositioning to decrease risk of skin injury and provide education on range of motion/bed exercises (The interventions failed to show any interventions specific to lymphedema treatment, including who was to perform the dressing changes, and/or for the SN to provide education to the hospice aide to change the dressings); and - SN interventions, added on 01/10/2024, included, in part: * Provide comfort kit for immediate palliation of symptoms * Teach/review appropriate use of medications in the comfort kit for potential management of symptoms, I.E., nausea, vomiting, pain, fever, anxiety, increased secretions, agitation, restlessness, and SOB (shortness of breath) * Obtain orders from physician for pain and symptom management * Assess and document the patient during pain and symptom crisis * Assess patient for uncontrolled pain and symptoms that cannot be managed at home * Educate on opioid pain medication * Educate patient and family on medication purposes and side effects * Educate patient and family when to call hospice agency and understanding of when to activate 911 emergency services * Evaluate effectiveness of routine and PRN medications * Assess for nausea vomiting and report nausea and vomiting to physician * Review medication sheet with patient family and caregiver * Teach about medication as ordered by physician for nausea and vomiting * Assess oxygen therapy * Monitor respiratory status and report changes to physician as ordered * Administer pain medications as prescribed * Encourage pursed lip breathing and deep breathing exercises * Teach safety precautions related to potential for falls * Educate caregiver on monitoring for signs and symptoms of new onset of confusion * Educate patient and family on when to contact care team for possible infection * Educate patient and family on proper hygiene including hand washing * Educate patient and family on signs and symptoms of infection * Monitor and report changes in condition * Monitor for weakness and fatigue * Assess the patient’s knowledge of current diet related to diabetes * Assess for s/s of hypoglycemia or hyperglycemia and report to physician promptly. Review of a client coordination narrative note, entered by an LPN (licensed practical nurse) on 01/12/2024, showed in part: - (The LPN) Notified patient “;emergency preparedness in effect with road conditions being poor;” - (Patient) “;Denied any emergent needs at this time;” - (Patient) “;Denied rescheduled visit;” - (Hospice) “;Will resume normal visits next week;” - (LPN) Coordinated with RNCM (registered nurse case manager); and - The clinical record failed to show documentation of follow-up by the RNCM, physician notification of the missed visit and/or orders for the hospice aide to perform the wound care/dressing changes. Review of a client coordination narrative note, entered by a LPN on 01/17/2024, showed, in part: - “;PT (patient) contacted this nurse regarding rash to bilateral arms;” - “;This nurse (LPN) and patient have had noted conversations in past regarding (his/her) allergy to doxycycline (antibiotic)”. (The clinical record failed to show any documentation of any skilled nurse visits since the SOC on 01/10/2024. The clinical record failed to show documentation of the past conversations between the LPN and the patient regarding the patient having an allergy to doxycycline. The documentation of the SOC was in a narrative note that was not entered into the EMR (electronic medical record) until 01/18/2024. The narrative note failed to include a complete comprehensive assessment of the patient, including all pertinent past medical history); - “;The patient previously wanted to continue to take it (doxycycline) regardless of minor reaction;” - “;Pt now requesting to stop” (taking the medication); - (The LPN) “;Coordinated with (medical director), okay to stop doxycycline and monitor;” - (LPN) “;Coordinated with RNCM;” and - The clinical record failed to show documentation of a follow-up and/or an assessment by the RNCM related to the new symptoms. Review of a client coordination narrative note, entered by an RN on 01/18/2024, showed in part: - The late entry was from a visit made on 01/10/2024; - “;Pt has been on Hospice service before last hospital admission to treat cellulitis which was unresponsive to oral antibiotics;” - “;Pt receives bilayer compression wraps for lymphedema, HHA (hospice/home health aide) educated on proper application procedure, and is able to complete return demonstration” (The clinical record failed to show documentation of the SOC comprehensive assessment, orders for the HHA to perform dressing changes for lymphedema treatment, and no documentation of a visit with education being provided and return demonstration); - “;Pt continues to have red raised rash on inner thighs;” - “;Pt also continues to c/o (complain of) of itching;” - “;Currently taking two oral antibiotics to help with cellulitis (doxycycline and cephalexin [antibiotic]);” and - The clinical record failed to show documentation of a follow-up by the RN regarding the complaints of itching and/or a comprehensive assessment by the RN. Review of a client coordination narrative note, entered by a HHA on, 01/25/2024, showed, in part, “;Pt in recliner upon arrival. Leg cares and wraps comp. Notified RNCM of changes/updates/needs. Pt in recliner on departure. Supplies delivered.” The clinical record failed to show documentation of what the patients changes/updates/needs were, follow-up from the RNCM, and documentation of the RNCM reassessing the patient with reported changes/updates/needs. Review of a client coordination narrative note, entered by an LPN on, 01/25/2024, showed, in part, the patient “;wears an insulin pump (durable medical device that supplies a continuous flow of insulin underneath the skin) and has a continuous blood sugar monitor (using a device to automatically estimate your blood glucose level),” and (LPN) “;coordinated with the RNCM.” The clinical record failed to show documentation on the POC (plan of care) for the continuous blood sugar monitor. The agency failed to provide documentation of a skilled nurse visit with a complete patient assessment and SN interventions provided. Review of a client coordination narrative note, entered by an LPN on 01/29/2024, showed, in part, the patient was seen for a routine nursing visit. The patient had increased pain in his/her back and legs. (LPN) unwrapped (patients) legs, soaked feet and rewrapped (legs). The “;patient is utilizing ABD (thick absorbent dressing to manage heavily draining wounds) pads at the top of the wraps” due to “;increased weeping.” “;Patient will need ABD Pads, cast wrap, and tape for next visit. Coordinated with HHA and RNCM” (The clinical record failed to show documentation of a follow-up from the RNCM and/or physician notification regarding the patients increased pain). Review of a client coordination narrative note, entered by a HHA on 01/31/2024, showed, in part, “;Pt in recliner upon arrival. Leg care and wraps comp. Notified RNCM of changes/concerns. Supplies delivered. Pt in recliner on departure.” The clinical record failed to show documentation of what the patients changes/concerns were, follow-up from the RNCM, and documentation of the RNCM reassessing the patient with reported changes/concerns. Review of a client coordination narrative note, entered by an LPN on 02/02/2024, showed in part, that the “;patient has complaints of increased itching. Patient states the redness has gone away but (he/she) continues to have itching on bilateral lower extremities as well as (his/her) back and upper extremities. Care coordinated with (hospice medical director) and new orders obtained.” The clinical record failed to show documentation of a follow-up and/or a reassessment by the RNCM. Review of the nurse practitioner’s face-to-face encounter note, with a visit date of 02/09/2024, showed, in part: - The patient stated that his/her back hurts so much, but he/she does not want to take increased APAP (acetaminophen- non-opioid analgesic medication used to treat pain) but would like increased hydrocodone (opioid analgesic used to treat severe pain) for pain; - He/she had a w/c (wheelchair) for longer distances out of the house due to SOA (shortness of air) with exertion; - Norco (hydrocodone/acetaminophen combined in one medication) for pain PRN was becoming less effective; - Uses a bipap for sleep; - Wounds to bilateral lower extremities that were treated with the dressing changed three times per week; - Extensive vascular staining to BLE with 2-3+ BLE edema despite Lasix (diuretic medication to treat fluid retention) use; - Sleeps in the recliner due to orthopnea (discomfort when breathing while lying down flat); - The patient had surgery for hydrocele (fluid filled sac around a testicle) and has had a slow recovery. (The clinic record failed to show documentation of this prior to this visit); - He/she had shortness of air with conversation and walking; - Had stopped taking doxycycline for cellulitis due to an allergy; - Weeping skin to LLE (left lower extremity) foot and toes as patient had taken dressing off of foot to allow it to dry out; - Legs to be rewrapped tomorrow (02/10/2024) by hospice staff. (The agency provided a coordination note report that had narrative notes but these notes did not include documentation of complete patient assessments); - The patient stated that he/she had a virtual visit last week but could not relay any of the information discussed; and - The patient stated his/her right eye kept wandering and when it does that, he/she just wants to sleep. The clinical record failed to show documentation of a comprehensive assessment by a RN identifying the patient issues prior to the face to face. Review of a client coordination narrative note, entered by an LPN on 02/12/2024, showed in part, that the “;Pt frustrated with insurance and the issues getting help from the VA. This nurse asked patient if (he/she) has discussed issues with RNCM. Pt states that (he/she) has not seen RNCM in a month just this nurse and HHA. Unsure if pt is confused, spouse agrees. Will discuss with (hospice) team on pt concerns.” The clinical record failed to show documentation of a discussion regarding the patients concerns, follow-up regarding the patients concerns, and/or a comprehensive assessment visit made by the RNCM. Review of a client coordination narrative note, entered by an LPN on 03/02/2024, showed in part, that the LPN documented a missed visit notification regarding a missed visit on 02/19/2024 (12 days after the missed visit). The reason for the missed visit showed, “;visits shouldnt have been plotted, I was not working.” The scheduler was notified on 2/6 (02/06/2024) and 2/18 (02/18/2024) and the RNCM was notified on 2/15 (02/15/2024). The clinical record failed to show an attempt to reschedule this visit for another day in the week. The patient had orders for treatment of lymphedema to BLE that included compression wraps to be changed three (3) times per week and the documentation failed to show who changed the dressings as ordered. Review of a client coordination late entry note, entered by the RNCM on 03/06/2024, showed in part, that the late visit documentation was from a visit dated 03/04/2024. The reason the documentation of this visit occurred after the actual in-home visit showed, “;completed in 48 hours.” (The clinical record failed to show any other documentation from the RNCM for a skilled nurse visit.) Review of a note typed on a plain piece of typing paper dated 03/18/2024, showed “;This nurse received TC (telephone call) from pt to move (his/her) RN nursing visit from Monday to Friday this week. Pt states (his/her spouse) has multiple appointments today and he/she will work around the HHA visit but, does not have time to work around both HHA and nursing”. Pt states (he/she) is very pleased with personal cares that (hospice) HHA provides. Pt also verbalizes appreciation for LPN services. Pt verbalizes that (he/she) does not need any refills at this time and appreciative for nursing services. The note failed to contain a signature. (The clinical record failed to show any RN visit after this telephone contact.) Review of an electronic secured message showed the following: - On 03/20 (03/20/2024), LPN D typed “;Starting (hydrocodone/ibuprofen) 10/200 pain not controlled with 7.5 mg (milligram). Sleeping more often. Vss (vital signs stable). Large blister to RLE below knee, drained once now filled with yellow thicker looking pus/slough, applied iodine to help dry out blister will need assessed next skilled nursing visit. Meds will also need to be filled next visit. I believe (he/she) is due for RN next (PCM B [patient care manager B]). Sent refill for Keflex (antibiotic that can treat infections) as well (HHA A and HHA B) please deliver meds and dental paperwork to pt tomorrow, paperwork will be at the office”; - On 03/21 (03/21/2024) at 3:04 PM, HHA A typed “;Does (patient) still need a med drop off? Happy to do it”; - On 03/21 (03/21/2024) at 3:11 PM, HHA B typed “;Yes please!”; - On 03/21 (03/21/2024 at 3:11 PM, PCM B typed “;(HHA A) when you get done with that, check with me I may also have a med drop off for (another patient), Im currently waiting on new orders from the medical director”; - On “;Tuesday 6:43 PM” (no date), showed LPN D typed “;Seems very pale, tired. Declining functionally, more SOA at rest and resp (respirations) sx (symptoms) presenting but pt seems to be deflecting of that when I ask or mention anything about breathing. Is NOT using BIPAP anymore, apparently hasnt been for a while but did not tell us. His/her machine was not working properly so he/she stopped. Its provided through (vendor), (he/she) said (he/she) will see about getting it fixed, (he/she) may need an appointment or something to have (his/her) settings adjusted, not super sure. I told (him/her) I would mention it to you (PCM B). Meds up for a week today. Legs look good, feet weeping some. No big changes. (PCM B)”; and - The clinical record failed to show if the RN provided appropriate supervision of the patient or identified the patient’s nursing needs related to respiratory decline and the need for durable medical equipment. Review of a LPN skilled nursing note dated 03/20/2024, showed, in part, the following: - The patient had increased weeping and a new blister to the right lower extremity, iodine added per physician and continue with wraps; - The patients pain was general and rated the pain 4/10 (the documentation did not include description of pain, what made pain better and/or worse, and/or if any pain medication taken) and the treatment was to increase Vicoprofen (hydrocodone [opioid medication]/ibuprofen [medication to reduce inflammation] used to treat pain); - The patient had orthopnea, used biPAP at night (no order in the clinical record), and refused oxygen (there was no education on the benefit of oxygen use and no order for oxygen); - The patient complained of uncontrolled pain with Vicoprofen 7.5 mg. Coordinated with the hospice medical director to discontinue current hydrocodone/ibuprofen and increase to 10 mg/200 mg one to two tablets every six hours for pain as needed; - The patient had large blister (the clinical record failed to include measurement, description of skin surrounding blister, and/or absence or presence of drainage with description) to RLE directly below his/her knee that had “;drained once” per the patient (the patient providing assessment) but had since refilled at the bottom with what appears to be slough like fluid. - The physician okayed applying iodine to help dry out blister and avoid infection. (The POC failed to include information regarding the patients blister, an order for iodine, or interventions. There were no further assessments regarding the blister.) Review of a client coordination note report written by PCM B, dated 03/22/2024, showed, in part, the following: - The patient was very pale in appearance and was having increased problems with his/her hands and unable to pick things up or hold on to things with his/her fingers and thinks it was related to osteoporosis in his/her spine; - It was becoming harder and harder for him/her to use his/her hand with this decline in dexterity and having trouble getting pills out of his/her pill box and setting up pill box; - The nurse offered to set up the pills during the visit but patient stated that he/she had enough pills in the box until Sunday and thought he/she would be able to set up the pills tomorrow; - The nurse offered again to set up the patient’s medication and he/she refused and stated that he/she would call Monday if he/she was unable to get the medication set up over the weekend; - Assessment was completed for an area of impaired skin integrity (clinical record failed to show an assessment and/or description) at the top of the patient’s right bilateral compression wrap, where he/she had a previous blister, this was now popped, and the patient stated he/she wanted to pull off the skin; - “;This area was covered with Vaseline gauze and calcium alginate is ordered. Then covered with bilayer compression wrap” (the clinical record failed to show an order for Vaseline gauze and calcium alginate); - The patient was educated on not pulling the loose skin off, the patient stated he/she does not understand why he/she could not do this (pull off the skin), he/she had alcohol and things to disinfect the area (the RNs documentation failed to clarify the skin the patient wanted to pull off or provide an assessment of the area to assess if there was a reason the patient wanted to pull the skin off. The clinical record failed to show if the skilled nurse completed a skin assessment to show if there was an issue with the patient’s skin.); - The patient denies pain at this time and verbalizes he/she was using the Vicoprofen for pain control and thinks it works better than the hydrocodone; - The patient continues on Keflex and stated he/she had not been taking the doxycycline but would like to know the hospice medical director’s recommendation for a second antibiotic, and care was coordinated with the Hospice medical director related to the patients antibiotics; - The patients cellulitis was under control at this time and the patient does verbalize that he/she might need IV antibiotics again to control the cellulitis and education was provided that the patient would not be able to receive IV antibiotics on Hospice, that those are considered aggressive measures, and he/she would need to come off hospice to receive IV antibiotics; - Physical assessment completed and the patient was alert and oriented times four (4). Lungs clear to auscultation, diminished in the bases bilaterally. Patient continues to complain of itching notably on upper arms bilaterally and across his/her back. The patient continues to have three to four plus edema, with vascular stasis seen in bilateral lower extremities. Patient has thickened skin over toes and feet; - The patient reported blood sugar (level of sugar in the blood) had been running around 235 (a normal blood sugar is below 140). The patient stated if (his/her) blood sugar was going to be high, it was exactly 235 every time (this was the only time there was documentation in the clinical record regarding blood sugars). The patient has an insulin pump and continuous (blood sugar) monitor; and - Education provided on using a seated roller walker for mobility outside his/her house. (Review of the clinical record showed on 01/14/2024 a social worker documented the patient was wheelchair bound. Review of a nurse practitioner’s face to face on 02/09/24, showed the patient required a wheelchair to leave home.) Review of the clinical record showed the patient was hospitalized in December 2023 for IV antibiotics due to cellulitis. Since the patient’s readmission to hospice in January of 2024, the patient failed to receive wound care for cellulitis by a nurse three times a week. The nurse failed to notify the physician of the elevated blood sugar or obtain orders/interventions for the insulin pump with continuous monitoring. Review of a LPNs skilled nursing note, dated 03/28/2024, showed, in part: - The patient’s pain was general and rated six (6) out of 10 and the treatment for the pain was routine hydrocodone/ibuprofen; - The patient had orthopnea and refused the biPAP at night; - The patient appears tired and stated that he/she was more tired lately and experienced more fatigue; - The patient reported that hydrocodone 7.5 mg/ibuprofen 200 mg one to two tablets every six hours as needed for pain did not get delivered and he/she was running out of his/her “;other dose”; - Instructed patient to contact hospice sooner when these things happen as it had been several days that the patient had gone without the dose; - Coordinated with several pharmacies and they do not have that dosage the patient was requiring, sent in a script to refill hydrocodone 7.5 mg/ibuprofen 200 mg ibuprofen per the hospice medical director until higher dose can be obtained from pharmacy (the clinical record failed to show an order for this medication); and - Patient without further changes or concerns and coordinated with PCM B. Review of the clinical record showed the hydrocodone 7.5 mg/ibuprofen 200 mg was discontinued on 03/20/2024 (eight days prior to this note). The clinical record failed to show an order for the hydrocodone 10 mg/ibuprofen 200 mg (LPN D documented this was a medication change on 03/20/2024). The clinical record failed to include follow up to show if the patient received medication. Review of the clinical record failed to show if the RN coordinated care and/or provided follow up regarding the concerns. Review of an LPN skilled nursing note dated 04/01/2024, showed the patients pain was general and rated six (6) out of ten and the treatment for pain was routine pain meds; - The patient had orthopnea and used a biPAP at night; - The patient reported he/she still never received the hydrocodone 7.5 mg/ibuprofen 200 mg tablets that were ordered last week, attempts were made over the weekend to get the medication to the patient and with the holiday, pharmacies were closed and the dosage was not able to be obtained; - The nurse inquired with other pharmacies regarding the higher dose with hydrocodone 10 mg, and the pharmacist explained that the medication was very expensive, and most pharmacies will not order it; - This information was coordinated with the hospice medical director and new orders were received for hydrocodone oral concentrate 20 mg/ml (milliliter) 0.5 ml to 1-ml every six hours as needed for pain and the patient was okay to take one to two tablets of ibuprofen 200 mg every six (6) hours as needed for pain; - The patient voiced understanding and okay with new orders; - The patient wanted to refill his/her tablets of hydrocodone 7.5 mg and it was explained that the patients physician would not approve that as he/she does not want the patient taking both at the same time and ensured the patient the medication would be picked up and delivered by the HHA tomorrow; and - This visit was coordinated with PCM B. The clinical record failed to show physician orders for hydrocodone oral concentrate and the medication was not listed on the client medication report. There was no documentation to show the RN coordinated care and/or provided follow up regarding the concerns. Review of the hospice IDG comprehensive assessment and plan of care update report, dated 04/03/2024 showed, in part, the following: - The hospice physician documented that the patient was having trouble getting the hydrocodone/ibuprofen that he/she likes for pain; and - PCM B documented “;new orders for hydrocodone liquid, as we are unable to get hydrocodone/ibuprofen 10/200 mg (review of the client medication report showed this was discontinued on 04/16/2024). New orders for 10 mg hydrocodone liquid and one (1) tablet ibuprofen every six (6) hours as needed for pain. The clinical record showed a physician order for hydrocodone 7.5 mg/ibuprofen 200 mg that was discontinued on 03/20/2024. The clinical record failed to show an order for the hydrocodone 10 mg/ibuprofen 200 mg on 03/20/2024. The clinical record failed to show an order for hydrocodone liquid. Review of a typed note on a plain piece of typing paper, entered by RNCM (patient care manager [PCM] B) dated 04/05/2024 showed, “;multiple telephone calls to pt to confirm visit today. No answer to phone calls. Finally able to reach pt via telephone to pt to confirm RN visit today. Pt states he/she and spouse have multiple appointments today and he/she will not be home. RN supervisory completed via TC. Patient verbalizes (he/she) is pleased with cares. Pt stated (he/she) is very pleased with HHA cares. He/She states HHA does a good job. Pt also states (he/she) is pleased with LPN who completes (his/her) visits. Pt reports that staff also delivers (his/her) medications for him which helps, otherwise (his/her family members) have to go to town to pick up medications. Pt verbalizes no additional needs at this time. Education to pt to call (hospice) 24/7 with any questions or concerns. (The clinical record failed to show a skilled nurse visit note made by the RN.) Review of a LPN skilled nursing note, dated 04/09//2024, showed, in part: - The section for a pain assessment and wound assessment failed to include assessment documentation ; - Oxygen saturation was 90% (normal oxygen saturation level is between 95% and 100%); - The patient had more labored breathing than he/she usually does at rest; - The patient stated that he/she was no longer using his/her biPAP at night due to the machine not working properly (this issue had been identified around 03/20/2024 and was still unresolved); - The patient denied hospice to provide a new one and he/she will speak to a medical equipment company. The social worker was notified; - The patient reported that “;beat” are weeping again and using abdominal padding for this; - The LPN coordinated with the “;HHA reports” and no new open areas or concerns to legs and no changes to treatment at this time (the LPN failed to assess/document the patients skin and relied on the HHAs charting for open areas and/or concerns); - The patient was noted to have overall weakness and appeared more tired, this seemed a new trend for patient with each visit; and - Coordinated with PCM B. Review of the clinical record failed to show the RN coordinated care and/or provided follow up regarding the concerns. Review of a client coordination late entry note, entered by the MSW (Master of Social Work) on 04/16/2024, showed in part, that the late entry narrative was for the social worker visit that was made on 04/10/2024 (six days after the visit). The patient stated he/she “;has continuous unmanaged pain. Also had complaints that nursing is not making scheduled visits. Attempted to address both of these topics but (he/she) was very evasive and kept repeating that he/she did not want to cause any problems.” (The social worker failed to include information regarding the biPAP not working.) The clinical record failed to show documentation, prior to surveyor arrival, of the patients concerns being addressed regarding the nurses not making scheduled visits and continued unmanaged pain. Review of an LPNs skilled nursing note, dated 04/12/2024, showed the patient continued to have increased shortness of air with exertion and refused the need for oxygen or intervention. The patient was visibly out of breath a lot lately. “;Educated pt regarding dx process. Voiced understanding.” Bilateral feet drying out as they have been weeping more the last visits and the wraps were clean, dry, and intact. (The LPN failed to document an assessment.) Coordination was with PCM B. (The LPN failed to document if the patient’s had a functioning biPAP.) (There was no documentation to show the RN coordinated care and/or provided follow up regarding the concerns.) The clinical record failed to show the RN coordinated care and/or provided follow up regarding the concerns. Review of a client coordination narrative note, entered by an LPN on 04/16/2024, showed in part, “;Telephone call made by this nurse to patient at 12:20 PM after visit to go over all changes to medications made during today’s SN/F2F encounter with physician. Each med addressed in depth including frequency, route and indication. Pt has a good understanding of all of (his/her) meds and voiced that after each med reviewed. Pt is without any concerns related to medication at this time. Phone call was made with PCM included ET PT was aware. Copy of MAR (medication administration record) being delivered to PT today by MSW and PT notified of this.” The clinical record failed to show any documentation of an assessment from PCM B (RNCM) after continuous changes in condition, unmanaged symptoms, and physician face-to-face with changes to the patients plan of care/orders. During a telephone interview on 04/16/2024 at 3:08 PM, the patient stated that the hospice wraps his/her legs twice a week due to the cellulitis which was very painful. He/she had no issues with pain at this time. He/she had lymphedema and the hospice used Coban to wrap his/her legs. He/she had never used, or been told about liquid hydrocodone. He/she use to take hydrocodone with Tylenol but was told that was hard on his/her kidney, he/she had only one kidney so as of today the hospice was adding Celebrex and increasing the “;hydrocodone” to 10 mg with ibuprofen. He/she currently takes “;hydrocodone 7.5 mg with ibuprofen” and that was not enough. The hospice had tried to control his/her symptoms but too many people were carrying messages back and forth like the medicines would not work or were too expensive. During an interview, on 04/17/2024 at 10:37 AM, the clinical director stated he/she expects staff to complete assessment documentation during the visit. He/she was sending the nurse and nurse practitioner out to do a visit and complete a full assessment with a medication reconciliation so they could straighten out the medications and get the symptoms under control.”

“Based on policy review, record review, home visit observation, and interview, the provider failed to ensure the staff documented responses to medications, symptom management, treatments, and services based on the problems identified in the comprehensive assessment and updated comprehensive assessments in two of four records reviewed (Records/Patients #1 and #2). This deficient practice has the potential to adversely affect the care provided to all the provider’s patients. Review of the provider’s policy titled, “Initial and Comprehensive Assessment of the Patient,” dated 10/26/2022, showed, in part, the following: - The hospice interdisciplinary team conducts and documents a patient-specific comprehensive assessment that identifies the patients need for hospice care, including medical, nursing, psychosocial, emotional and spiritual care; and - The interdisciplinary team treats and prevents symptoms of the patients disease and/or co morbidity factors based on findings in the comprehensive assessment and reassessments. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 04/01/2024 with a terminal diagnosis of malignant neoplasm of bladder (bladder cancer). The patient resided at home with a family member. Review of the start of care assessment, dated 04/01/2024 at 6:06 PM, showed, in part, the following: - The patient reported moderate pain rated a seven (7) (a scale used to rate pain, zero (0) representing no pain and 10 representing the worst pain possible) to his/her back, and the pain was stinging, tender, and sharp. Changes in weightbearing and medications relieved the pain; and - The patient had a vascular access port implanted (port-a-cath [an implanted port under the skin that is placed in a vein to allow medicine or nutrition to be sent into the bloodstream]), the dressing was changed at the medical center, it had good blood return (there were no orders to access the port) and it was not accessed during the admission visit. (The documentation failed to clarify how there was good blood return if the port was not accessed.) Review of the plan of care (POC) dated 04/01/2024 showed the following: - Lidocaine pain relief 4% topical patch (helps to relieve pain and works as a local anesthetic) daily to right lower back; - The POC failed to contain information regarding the port-a-cath; and - The POC failed to include individualized interventions for pain management. Review of a physicians order, dated 04/09/2024, showed an order to flush the port-a-cath with 200 cc (cubic centimeter-a measurement for liquids) of 0.9% normal saline then flush with 5 cc/100 unit of heparin (an anticoagulant) using the existing line and then discontinue (deaccess [remove needle] from the port). The physician order was not processed until 04/15/2024 (six days later) and was added to the medication profile on 04/15/2024. The physician order showed “;this order has been declined”. Review of the nurse note dated 04/09/2024 at 9:45 AM, showed the hospice medical director was notified, with orders received for care of the port-a-cath and this nurse was unable to enter orders at this time related to not having company access. A call was placed to the clinical director who agreed to enter the orders and call the pharmacy for delivery tomorrow (04/10/2024). Review of the nurse note dated 04/12/2024 at 1:57 PM (three days after orders were received to remove the port-a-cath), showed the patient asked about the port (port-a-cath) and a message was sent to the clinical director. The patient asked about the lidocaine patches, the providers pharmacy showed the lidocaine patches were at the local pharmacy (the pharmacy the patient used) and the patients family member stated he/she would pick up the lidocaine patches. Observation during a home visit on 04/15/2024 beginning at 12:00 PM, showed the patient had an accessed port on his/her right chest wall and the dressing was coming off. Per interview conducted during a home visit observation on 04/15/2024 beginning at 12:00 PM, the patient stated that he/she was not happy with his/her port and wanted it out. The patients family member stated that the nurses have been trying to get the heparin but they are having trouble finding any. The patient had received lidocaine patches at the hospital and has not had them since he/she was admitted to hospice. The patient stated that his/her pain usually was rated a four (4) to six (6) and the lidocaine would make it a zero (0). The patients daughter stated the lidocaine patches had been at the pharmacy for three days but there was a co-pay. During this visit the hospice nurse stated that hospice would pay for the lidocaine patches. The family member checked with the pharmacy toward the end of the observation visit and stated that the co-pay had just been lifted. The family member also stated that the hospice provider had given him/her lidocaine “;strips” to use temporarily. Per interview conducted during a home visit observation on 04/15/2024 beginning at 12:00 PM, registered nurse (RN) D stated that the provider will pay for the lidocaine patches. The heparin was not available from the pharmacy (the clinical record showed the order was not added until 04/15/2024, 15 days after the start of care). He/she stated the port-a-cath dressing was dated 03/26/2024 and it did not have to be changed but once a month (The clinical record failed to contain orders to change the dressing). He/she would have to run back to the office to obtain the dressing supplies to change the port-a-cath dressing (The clinical record failed to contain orders to change the port-a-cath dressing). Review of a physician order dated 04/16/2024 at 1:09 PM (day after home visit), showed an order to clarify the order written on 04/09/2024, that showed the dressing to the port-a-cath should be changed monthly and as needed if dislodged or soiled. There was no documentation regarding the physician orders on 04/09/2024 to discontinue/deaccess the port-a-cath. The clinical record failed to show physician orders for the port to be flushed. During an interview on 04/17/2024 at 10:37 AM, the clinical director stated that the provider uses Better RX as the benefit manager. Better RX will reach out to the patients pharmacy to have them change the insurance to show hospice is the payer and the patients pharmacy had 14 days to change the profile. The heparin order was written and put on the medication list yesterday (04/16/2024, 15 days after patient admitted) and sent to the pharmacy. When asked if the patients lidocaine had been filled since admission (04/01/2024) he/she stated the insurance was changed yesterday (04/16/2024) and hospice will pay for the lidocaine patches. He/she had found a box of lidocaine patches in his/her office desk drawer and gave the patient strips so he/she could place the strips side by side like he/she liked. The clinical director did not have the packaging the lidocaine patches came in, but stated they were not expired and were the right dose. RECORD/PATIENT #2: Review of the patients clinical record showed the patient was admitted to hospice on 03/06/2024, with the terminal diagnosis of cancer of the left tonsil fossa (cancer of the tonsil). The patient resided at his/her home with a family member. The patients date of death was 03/11/2024. Review of the physician office visit note, dated 03/01/2024, showed, in part, the patient had an allergy to opioids (a class of drugs used to reduce moderate to severe pain) morphine (derived from opium and used to treat pain) analogues (a compound with a molecular structure like that of another). The patients clinical record failed to include information regarding an opioid/morphine allergy. Review of the start of care visit made by the QA (quality assurance) nurse on 3/06/2024 at 6:27 PM showed, in part, the following: - The documentation was completed on 03/14/2024 (eight (8) days after the start of care visit and three (3) days after the patients death); - The patient had left sided periorbital edema (swelling or puffiness around the eye region) that extended down the left side of face and the left eye was significantly swollen. Three plus bilateral lower extremity edema (swelling of the bodys tissue) with weeping (swelling becomes so severe fluids will leak out directly from the skin). (The clinical record failed to show any discussion and/or interventions of any follow up regarding the periorbital edema and bilateral extremity edema with weeping); - Excessive bleeding or bruising and anticoagulant (medicine that prevents clots) therapy. Review of the IDG (interdisciplinary group) meeting notes dated 03/11/2024 (date of patients death) failed to show documentation of a discussion of anticoagulant therapy and interventions regarding the excessive bleeding and/or bruising; and - The patient was having significant pain to the head region and currently only taking Tylenol (used to treat minor aches and pains) and stated the oncologist would not give him/her anything for pain. He/she rated his/her pain a seven (“;7”) (a scale used to rate pain, zero (0) representing no pain and 10 representing the worst pain possible). Waiting on return call for new orders, and the “;patient currently does not have any medications” (the documentation showed the use of Tylenol). (The documentation failed to clarify what orders the nurse was waiting on, interventions to manage the patients pain other than “;awaiting new orders” and follow up regarding the use of Tylenol.) Review of the skilled nurse visit made by PCM (patient care manager) A on 03/07/2024, showed in part, the following: - The documentation was completed on 03/21/2024 at 5:18 PM (14 days after the visit was completed and 10 days after the patients death); - The patient was currently under treatment for dyspnea (shortness of breath) that significantly affected the patient. (The clinical record failed to include treatment for dyspnea); - The patient had four (4) plus edema (pitting edema, when pressure is applied to the swollen area, an indentation will remain) to both lower extremities. (The plan of care failed to include interventions for the edema to the lower extremities); - The patient had a cough with moderate sputum, the color of the sputum showed bloody drainage from the tonsil cancer. (The plan of care failed to include individualized interventions to manage the bloody drainage); and - The patient shakes his/her head no to allergies. The patient complained of pain to his/her head and neck and spits out blood from bleeding cancer to tonsils. Roxanol (morphine sulfate and is a highly concentrated solution of the narcotic analgesic morphine sulfate and used for the treatment of severe, chronic pain) and hydrocodone (a semi-synthetic opioid and used to treat severe chronic pain) ordered for the family member to pick up. (The documentation failed to show if the physician was notified of the morphine allergy before the Roxanol was ordered, of education provided to the family on the administration of Roxanol and hydrocodone, of the potential for an allergic reaction due to the patients morphine allergy, and included no interventions for managing the patients pain other than the family picking up the pain medication.) Review of the skilled nurse visit made by PCM A on 03/08/2024 at 4:31 PM, showed in part, the following: - The documentation was completed on 03/26/2024 at 4:26 PM (completed 18 days after the visit was done and after the patients death); - The patients pain was moderate, fidgeting, facial grimacing, no need to console, and the pain was rated a six (6); - Morphine was ordered on 03/07/24, the patient had two doses, the meds helped with pain but caused the patients thinking to be changed and the patient did not like the side effects. (The documentation failed to include an assessment of the pain after the morphine was administered.); - The order for hydrocodone (semi-synthetic opioid and used to treat moderate to severe pain) was waiting to be filled at pharmacy; - The patient did take five (5) mg (milligrams) of morphine and was more relaxed at end of the skilled nurse visit, the “;Patient had only been using Tylenol. Morphine listed on allergy list that dtr showed today. No true allergy but med side effects noted.” (The clinical record failed to show a physicians order for Tylenol and physician notification the patient had an allergy to morphine); - The patient took morphine and then his/her “;thinking was off”, and he/she hallucinated and did not take further (morphine) since the family member found a list of allergies which included morphine; and - The nurse instructed the patient “;this” was a common side effect and not an allergy. The patient was willing to take the medication for the pain, and the patients pain decreased by the end of the visit. (The nurse failed to provide assessment, rating and location of pain.) Review of the coordination note dated 03/10/2024 (no time), showed a licensed practical nurse (LPN) documented the following: - On 03/10/2024 (no time), a call was received from the patients daughter and the patient had swelling to his/her left eye and thought the patient was allergic to the liquid hydrocodone and the patient will not take it and requested an alternative medication for pain control and the nurse was to follow up tomorrow (03/11/2024); and - On 03/10/2024 (no time), new orders were received from the hospice medical director to discontinue the hydrocodone (the hydrocodone was not discontinued) and start Dilaudid (it can treat moderate to severe pain) every four hours as needed for pain, the patient care manager A will make a visit to the patient tomorrow (03/11/2024). (The clinical record failed to include any follow-up by the nurse. The last nurse visit was on 03/08/2024, two days prior, and the nurse failed to assess/document the patients pain, allergy, management of the patients pain, or the provision of education to the family. The patient’s date of death was 03/11/2024.) During an interview on 04/17/2024 at 8:49 AM, PCM A stated that: - Staff are unable to document in the electronic medical record (EMR) until the admission nurse completes the start of care documentation; - The admission nurse did not complete the start of care documentation until after the patients death; - When he/she provided the nurse visit on 03/07/2024, he/she did not receive any information about the patient, there was no plan of care, and he/she had to talk to the patients family member to figure out the medications and care of the patient; - The patient was on a few meds like Tylenol and was in quite a bit of pain and so he/she ordered comfort medications during the visit on 03/07/2024; - On 03/08/2024 he/she was shown a list of allergies that was provided to the family from another provider that included multiple allergies along with morphine; - The night before (03/07/2024) the patient did not have a reaction to the morphine but did not like the way the morphine made him/her feel; - He/she was instructed by the provider not to use paper charting, so he/she documented the patients visits in a personal notebook because he/she was unable to document in the clinical record; - He/she kept checking the EMR to see if it was ready for him/her to document and it took “;them” almost one week to open the chart and he/she still didnt have access to the chart until after the patient died; - He/she had his/her own plan of care in his/her “;head” until the chart was open; - The patient was in so much pain, taking hydrocodone, and thought he/she had a reaction, he/she (nurse) thought it was the cancer, and the patient decided to go ahead and use the morphine because the pain was so bad; - The QA nurse sent him/her a message that he/she just completed the admission visit and that pain medications were needed; - The QA nurse did not order medications on admission so he/she (PCM A) had to order the medications the next day (03/07/2024); - The medication are normally ordered during admission; - He/she did not notify the physician of the morphine allergy because it was not a true allergy; and - He/she did not have access to the referral records and the medications that the patient was taking prior to admission. During an interview on 04/17/2024 at 10:37 AM, the clinical director stated he/she expects staffs documentation to be completed by the end of the visit and address all the patients problems.”

“Based on policy review, record review, and interview, the provider failed to ensure physician orders were obtained in one of four records reviewed (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Physician Orders” dated “;Dec09”, showed, in part, the following: - Verbal orders are obtained to provide new medication, change in medication or discontinuance of medication, and services or equipment to meet the needs of the patient; and - Documentation of receipt of the verbal order and of the written order sent to the physician for signature and maintained in the patients clinical record. RECORD/PATIENT #2: Review of the patients clinical record showed the patient was admitted to hospice on 03/06/2024 with the terminal diagnosis of cancer of the left tonsil fossa (cancer of the tonsil). The patient resided at his/her home with a family member. The patients date of death was 03/11/2024. Review of the start of care visit made by the QA (quality assurance) nurse on 03/06/2024 at 6:27 PM showed, in part, the following: - The documentation was completed on 03/14/2024 (documentation completed eight (8) days after the start of care and three (3) days after the patients death). - The patient had excessive bleeding or bruising and anticoagulant (medicine that prevent blood clots) therapy; and -The patient was having significant pain to the head region and currently taking Tylenol (used to treat minor aches and pains) and stated the oncologist would not give him/her anything for pain. The clinical record failed to include physician orders for Tylenol and anticoagulant therapy. Review of the skilled nurse visit made on 03/08/2024 at 4:31 PM showed, in part, the following: - The documentation was completed on 03/26/2024 at 4:26 PM (documentation completed 18 days after the visit was made and 15 days after the patients death); - The patient had nausea that significantly affected the patient and the patient had current medications for nausea/vomiting; and - The patient was spitting out blood several times a day from the cancer and “ordered suction” (machine, type of medical device that is primarily used for removing obstructions) to help clear mouth of bloody secretions. The clinical record failed to include physician orders for nausea/vomiting medications or a suction machine. During an interview on 04/17/2024 at 8:49 AM, PCM A stated that: - When he/she provided the nurse visit on 03/07/2024, he/she did not receive any information about the patient, there was no plan of care, and he/she had to talk to the patients family member to figure out the medications and care of the patient; and - The patient was on a few meds like Tylenol and was in quite a bit of pain and so he/she ordered comfort medications during the visit on 03/07/2024. During an interview on 04/17/2024 at 10:37 AM, the clinical director stated he/she expects staff to obtain physician orders for all medications and treatments.”

“Based on policy review, record review, and interview the provider failed to ensure that documentation was complete, completed in a timely manner, accurate, and/or authenticated by the person giving care in, but not limited to, two of four records reviewed (Records/Patients #2 and #4). This deficient practice has the potential to affect all patients served by the provider. Review of the provider’s policy titled, “Clinical Records,” dated 05/13/2014, showed, in part, the following: - A clinical record is established and maintained for every patient receiving care and services from the hospice provider; - The record is complete, promptly and accurately documented, readily accessible, and systematically organized to facilitate retrieval; - Entries are made in the clinical record for all services provided (both services provided directly and through contracted providers) in a standardized format and are legible, clear, and complete and signed and dated by the person providing the services; and - Each patient’s clinical record includes, at a minimum, the following: * Referral information and pertinent medical history * The initial plan of care, updated plans of care, initial assessment, comprehensive assessment and updated comprehensive assessments, clinical notes * Documentation of the patients responses to medications, symptom management, treatments, and services. Review of the provider’s policy titled, “Documentation Requirements,” dated 10/26/2022, showed, in part, the following: - Members of the interdisciplinary group (IDG) document the interventions provided to the patient/caregiver, their response to care, services provided, and the goals and outcomes achieved; - Documentation must be legible, grammatically correct, accurate, and timely; - All documentation contains complete, factual, essential, and accurate information. Staff and volunteers clearly state what was seen (assessment), what was done (intervention) and how the patient/caregiver reacted (outcome); and - The clinical record documentation will be completed within 48 hours and sync note. RECORD/PATIENT #2: Review of the patients clinical record showed the patient was admitted to hospice on 03/06/2024, with the terminal diagnosis of cancer of the left tonsil fossa (cancer of the tonsil). The patient resided at his/her home with a family member. The patients date of death was 03/11/2024. Review of the start of care visit made by QA (quality assurance) nurse on 03/06/2024, showed the documentation was completed on 03/14/2024 (eight (8) days after the start of care and three (3) days after the patients death), and showed, in part, the following: - The late documentation of this visit occurred after the actual in-home visit due to the start of care visit was not available to the nurse at time of admission; - The drive time began 03/05/2024 (one day prior to the patients admission); - The patients vital signs were completed on 03/05/2024 (one day prior to the patients admission to hospice); - The patient had excessive bleeding or bruising and anticoagulant (medication that helps prevent blood clots) therapy; and - The patients pain assessment showed the nurse documented the pain was rated a seven (7) (a scale used to rate pain, zero (0) representing no pain and 10 the worst pain possible) and in the narrative note the patient rated his/her pain an eight (8). The patient was having significant pain to the head region and currently taking Tylenol (used to treat minor aches and pains) and stated the oncologist would not give him/her anything for pain. The “;patient currently does not have any medications” (The documentation showed the patient was taking Tylenol and anticoagulant therapy); and - The patient had a gastrostomy/J-tube/PEG (feeding tube [and the type of feeding tube was not documented]). Review of the hospice certification of terminal illness (CTI) document dated 03/06/2024 at 9:15 PM (this hospice CTI included the date of the patient’s death), showed, in part, the following: - The patient had a diagnosis of squamous cell carcinoma of the left tonsil fossa, patient diagnosed in June 2023. Patient had a significant decline in functional status, the patient had been dependent upon a feeding tube since a stroke in 2021 and the patient has been wheelchair bound since the stroke. The patient was “;admitted to service on 03/06 and died on 03/11” (the verbal certification was dated 03/06/2024). The patient no longer wished to receive aggressive treatment and requested only comfort care under hospice services; - “;Attestation: I confirm that I composed the narrative above and that is based on my review of the patients medical record and/or examination of the patient” and the physician signed the form 03/19/2024 (21 days after the patients start of care and eight (8) days after the patients death). Review of a skilled nurse visit made by PCM (patient care manager) A on 03/07/2024 showed documentation was completed on 03/21/2024 at 5:18 PM (completed 14 days after the visit was completed and 10 days after the patients death). Review of a coordination note dated 03/12/2024 at 5:06 PM (one day after the patients death) showed, in part, the following: - Late entry documentation for nursing visit made on 03/07/2024 at 6:26 PM (five days after the actual visit); - Documentation of this visit occurred after the actual in-home visit due to the “;start of care visit not available to this nurse at time of admission”; - The patient was having significant pain to the head region and currently taking Tylenol (used to treat minor aches and pains) and stated the oncologist would not give him/her anything for pain. He/she rated his/her pain at an eight (8) (a scale to rate pain, zero representing no pain and 10 representing the worst pain possible), awaiting on return call for new orders and the “;patient currently does not have any medications”. (This late entry visit note was documented one day after the patients death.) Review of the skilled nurse visit made by PCM A on 03/08/2024 at 4:31 PM showed, in part, the following: - The documentation was completed on 03/26/2024 at 4:26 PM (documentation completed18 days after the visit was made and 15 days after the patients death); - The “;Patient had only been using Tylenol. Morphine (used to treat moderate to severe pain) listed on allergy list that dtr (daughter) showed today. No true allergy but med side effects noted”; and - The nurse instructed the patient “;this” was a common side effect and not an allergy and the patient was willing to take the medication now for the pain, and the patients pain decreased by the end of the visit (the documentation failed to show clear and accurate documentation regarding what PCM A was referring to as a common side effect or documentation of a complete follow-up pain assessment). Review of the skilled visit made by PCM A on 03/11/2024 at 4:31 PM showed, in part, the following: - The documentation was completed 03/26/2024 at 5:35 PM (14 days after the patients death); - Documentation of this visit occurred after the actual in-home visit due to “;waiting on note to end charting”; and - The time of death (TOD) was 9:13 AM, “;the patient was in recliner no resp no pulses TOD 0913 on 03/11/2024. Family grieving at this time.” (PCM A visit started at 4:31 PM, this is approximately eight (8) hours after the patients death.) Review of a coordination note documented by the QA (quality assurance) nurse on 03/12/2024, showed in part, the medical director gave verbal certification that the patients prognosis was six months or less if the disease runs it normal course (six (6) days after the patients start of care and one (1) day after the patient death). During an interview on 04/17/2024 at 8:49 AM, PCM A stated that: - Staff are unable to document in the electronic medical record (EMR) until the admission nurse completes the start of care documentation; - The admission nurse did not complete the start of care documentation until after the patients death; - When he/she provided the nurse visit on 03/07/2024, he/she did not receive any information about the patient, there was no plan of care, and he/she had to talk to the patients family member to figure out the medications and care of the patient; - The patient was on a few meds like Tylenol and was in quite a bit of pain and so he/she ordered comfort medications during the visit on 03/07/2024; - On 03/08/2024 he/she was shown a list of allergies that was provided to the family from another provider that included multiple allergies along with morphine; - The night before (03/07/2024) the patient did not have a reaction to the morphine but did not like the way the morphine made him/her feel; - He/she was instructed by the provider not to use paper charting, so he/she documented the patients visits in a personal notebook because he/she was unable to document in the clinical record; - He/she kept checking the EMR (electronic medical record) to see if it was ready for him/her to document and it took “;them” almost one week to open the chart and he/she still didnt have access to the chart until after the patient died; - He/she had his/her own plan of care in his/her “;head” until the chart was open; - The patient was in so much pain, taking hydrocodone (used to treat severe chronic pain that requires opioid analgesia), and thought he/she had a reaction, he/she (nurse) thought it was the cancer, and the patient decided to go ahead and use the morphine because the pain was so bad; - The QA nurse sent him/her a message on 03/06/2024 letting him/her know the admission visit was completed and pain medications were needed; - The QA nurse did not order medications on admission so PCM A ordered the medications the next day (03/07/2024) during his/her visit; - The medication are normally ordered during admission; - He/she did not notify the physician of the morphine allergy because it was not a true allergy; and - He/she did not have access to the referral records and the medications that the patient was taking prior to admission. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice on 01/05/2024, with a terminal diagnosis of malignant neoplasm of right kidney (cancer of the right kidney). The patient resided at home with his/her spouse. Review of the client coordination notes report showed the following: - On 01/10/2024, the corporate compliance officer documented the nurse failed to admit the patient on 01/05/2024; - On 01/14/2024, late visit documentation was completed by the social worker for the evaluation visit made on 01/11/2024 (three days after the visit); - On 01/17/2024, the licensed practical nurse (LPN) documented the patient contacted him/her regarding rash to bilateral arms, the patient requested to stop doxycycline (antibiotics) due to allergy, the physician was “;okay” to stop doxycycline. (Review of the client medication report and plan of care (POC) failed to show an order for doxycycline [antibiotic]); - On 01/18/2024, the RN C documented a late narrative from the visit made on 01/10/2024 (eight days after the visit), the patient continues to have raised rash on inner thighs and continues to complain of itching, and currently taking doxycycline and cephalexin (antibiotic) to help with cellulitis. (Review of the client medication report and POC medication list failed to show doxycycline and the clinical record showed cephalexin (antibiotics) was started on date 03/02/2024 (51 days later); - On 01/18/2024, the RN C noted that the medical director gave a verbal certification for terminal illness (eight days after the start of care visit was made); - On 01/25/2024, the RN C documented a narrative note to attest to completing the start of care on 01/05/2024 (on 01/10/2024, the corporate compliance officer documented the nurse failed to admit the patient on 01/05/2024); - On 01/25/2024, an LPN documented the patient wears an insulin pump (wearable medical device that supplies a continuous flow of insulin underneath the skin) and had a continuous blood sugar monitor. (The clinical record failed to contain physician orders and/or interventions for the continuous blood sugar monitor and/or to monitor blood sugars); - On 01/29/2024, an LPN documented a late nurse note from the visit made on 01/26/2024 (three days after visit) that showed the patient had increased weeping to bilateral legs and the patient was no longer taking doxycycline. (Review of the client medication report and POC failed to show an order for doxycycline; - On 02/10/2024, the nurse practitioner documented the patient used a biPAP (a form of non-invasive ventilation therapy used to facilitate breathing) for sleep, and had a wound to bilateral extremities that was treated with a dressing changed three times per week. (Review of the POC failed to show the biPAP and any skilled nursing orders/interventions for wound care and plans to change the dressing three times a week as the current o rders were for nursing two times a week); and - On 03/02/2024, an LPN documented a missed visit notification regarding a missed visit on 02/19/2024 (12 days after the missed visit) and the missed visit reason was “;visits shouldnt have been plotted, I was not working”. Review of the hospice IDG (interdisciplinary group) comprehensive assessment and plan of care update report for the IDG meeting on 02/21/2024, showed in part, a client order for the hospice recertification plan of care update with an order date of 02/21/2024, effective date of 03/05/2024, and an approved date of 04/16/2024. (The date the order was entered into the EMR was on 04/16/2024 [55 days later], during the survey). Review of the physician order for the hospice recertification plan of care (POC) for certification period of 03/05/2024 to 05/03/2024, showed, in part: - An order date of 02/21/2024; - Order type: Hospice recertification POC update; - Verbal order had “;N” (no); - Send to the physician “;Y” (yes); - Order description included orders for service type and frequency, discipline interventions, medications, supplies, level of care, and patient diagnoses; - The order was completed and electronically signed by the clinical director on 04/16/2024 (55 days after the order was received). Review of the client coordination notes report showed the following: - On 04/03/2024, an LPN wrote a narrative note for the visit made on 03/26/2024 (8 days after the visit) with the reason for late entry being “;no visit to chart on in system at this time”; - On 04/03/2024, review of the skilled nurse visit completed by an LPN on 03/28/2024 (six (6) days after the visit) showed the visit documentation was completed on a paper skilled nursing note. A paper addendum to the skilled nursing note page showed an electronic narrative note from 04/03/2024 was scanned onto the paper nursing addendum and was covering portions of the paper altering the original addendum nursing note. The original nursing addendum note was signed by the patient on 03/28/2024. (The patient had signed the paper visit note on 03/28/2024 that did not include the narrative from 04/03/2024). - On 04/03/2024, review of the skilled nurse visit completed by an LPN on 04/01/2024, showed the visit documentation was completed on a paper skilled nursing note. A paper addendum to the skilled nursing note page showed an electronic narrative note from 04/03/2024 was scanned onto the paper nursing addendum and was covering portions of the paper altering the original addendum nursing note. The original nursing addendum note was signed by the patient on 04/01/2024. (The patient had signed the paper visit note on 04/01/2024 that did not include the narrative from 04/03/2024); and - On 04/16/2024, a social worker wrote a note for the visit made on 04/10/2024 (six days after the visit), the patient had unmanaged pain and complained that nursing was not making their scheduled visits. The patient denied wanting a follow-up with nursing. During an interview on 04/17/2024 at 10:37 AM, the clinical director stated he/she expected the staff to complete assessment documentation during their visit. During an interview on 04/17/2024 at 10:23 AM, corporate nurse B stated that the branch office was sending over patient #4s nurse notes. (The skilled nurse visit notes provided to this surveyor were documented on paper skilled nurse visit notes until the visit on 04/16/2024). During an interview on 04/17/2024 at 10:23 AM, the corporate compliance officer stated that staff are not to chart on paper skilled nurse visit notes for more than 48 hours. There was a “;glitch in the system just for visit notes”. He/she had called the EMR companies technical support on 04/16/2024 at 3:49 PM, to inquire if a ticket had been submitted for the glitch and a ticket had not been submitted.”

“Based on policy review, record review and interview the provider failed to document the comprehensive assessment when the patient had a change in condition in one of four records reviewed (Record/Patient #3). This deficient practice has the potential to affect all patients receiving hospice care. Findings included: Review of the providers policy titled, “;Assessment-Initial and Comprehensive Assessment of the Patient,” revised 10/26/2022, showed in part, the following: - The hospice interdisciplinary team conducts and documents a patient-specific comprehensive assessment that identifies the patients need for hospice care, including medical, nursing, psychosocial, emotional and spiritual care; - The patients comprehensive assessment is updated at a minimum every 14 days; - The hospices assessment and reassessment tools contain data elements that allow for the measurement of outcome; and - The interdisciplinary team treats and prevents symptoms of the patients disease and/or comorbidity factors based on findings in the comprehensive assessment and reassessment. RECORD/PATIENT #3: Review of the patients clinical record showed the patient was admitted to the hospice provider on 12/18/2023 with a terminal diagnosis of sarcopenia (an age related, involuntary loss of skeletal muscle mass and strength) and resided at home. Review of a social worker note dated 01/18/2024 at 2:04 PM, showed the patient had a stroke Monday (01/15/2024), and he/she was no longer eating or drinking. The patient would moan in pain and the family was understanding of the dying process. Review of a team conference note provided by the administrator, dated 01/18/2024, showed that the clinical manager received a call from registered nurse (RN) A on 01/15/2024 during RN As nursing visit with the patient, when it was identified that the patient needed comfort medications due to his/her terminal decline. The skilled nurse failed to document a comprehensive assessment when the patient’s condition changed and showed a required change in the plan of care. During an interview on 01/30/2024 at 11:29 AM, the clinical manager stated that RN A provided a nurse visit to the patient on 01/15/2024, during the visit, RN A had called the clinical manager to report that he/she was extremely tired due to his/her pipes busting the night before. The visit was extended due to the patients change in condition. The clinical manager picked up the patients medications from the pharmacy that RN A had ordered. The clinical manager stated that RN A was very fatigued and had reached out to him/her for help. During an interview on 01/31/2024 AM, the patients family member stated on 01/15/2024 the patient had a stroke and RN A arrived to do a nurse visit. RN A was on his/her I-pad falling asleep. The clinical manager showed up at the patients home to help RN A. The provider did coordinate care after the patients stroke and the patient declined very quickly. During an interview on 01/31/2024 at 10:15 AM, the administrator stated he/she was unable to find the nurses note from the nurses visit on 01/15/2024, the day the patient had a stroke. He/she was unable to find written documentation in the clinical record for the comfort medications ordered on 01/15/2024. He/she would have expected RN A to document the visit or the clinical manager to do the assessment and document.”