Unity Hospice Gsl, LLC

“Based on policy review, clinical record review, and interview, the hospice provider failed to ensure that patients received effective symptom control for wound pain and urinary tract infection in one of three revocation records reviewed (Record/Patient #8). This deficient practice has the potential to affect the pain and symptom management of all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Patient Rights Policy Addendum A,” revised January 2014, showed in part the patient has the right:- To receive effective pain management and symptom control from the hospice for conditions related to the terminal illness; and - To receive information about the scope of services that hospice will provide and specific limitations on those services. RECORD/PATIENT #8:Review of the clinical record showed the patient was admitted to hospice services on 11/18/2024 with a terminal diagnosis of brain cancer and a secondary diagnosis of pressure sores (skin injury caused by unrelieved pressure) on the buttocks and genitalia. The patient resided at the home of a friend and his/her friend was the primary care giver (PCG). Review of the nursing visit note patient assessment, dated 01/14/2025, showed the following genitourinary (GU) findings:- The patient had a 16 French, 10 milliliter (ml) bulb (the size of the catheter tube/bulb), indwelling urinary catheter (a sterile tube placed in the bladder to drain urine);- Urine output- good;- Urine color – amber (normal = pale to light yellow);- Sediment /cloudy appearance (normal = clear);- Unusual odor- foul smelling (can indicate dehydration, urinary tract infection (UTI), certain foods, medications, or underlying health conditions like kidney problems or liver disease); and- A note that showed the nurse removed the leaking urinary catheter, replaced it with a new urinary catheter and obtained immediate output of 900 ml of amber urine.During the 01/14/2025 visit, the skilled nurse (SN) documented a discussion with the social worker (SW) that concerned the patient’s need of possible long-term care facility (LTCF) placement due to the high level of care required. The SN and SW planned to visit and assess the patient’s needs together on 01/21/2025. Review of the nursing visit note patient assessment, dated 01/17/2025, showed the following GU assessment findings: - An indwelling urinary catheter was in place, dependent to gravity, draining dark amber urine with 650 ml output; and - The SN failed to document additional genitourinary assessment findings during the 01/17/2025 visit. Review of the nursing visit note / psychosocial visit note, dated 01/21/2025, showed the following: -The purpose of the visit was to discuss a respite stay for the patient;- The patient rated their pain as a 10/10 (using a zero (0) to 10 pain scale in which 0 indicated no pain and 10 indicated the worst possible pain);- The patient was hollering out during the visit, and wanted to go to the hospital due to genital pain from the urinary catheter and the wound on his/her genitalia; and- The patient revocated hospice services on 01/21/2025 and was transported to the hospital by emergency medical services (EMS) on 01/21/2025. Review of the patient’s hospital emergency department records, dated 01/21/2025, showed the following diagnoses: -Urinary tract infection; and- Leukocytosis (a condition characterized by an elevated white blood cell (WBC) count. Elevated WBCs are often a sign of infection). During an interview on 03/25/2025 at 12:30 PM, the registered nurse coordinator stated that the nurse should have informed the patient’s physician of the 01/14/2025 genitourinary assessment findings and symptoms.”

“Based on policy review, review of the provider’s complaint log, and interview, the hospice provider failed to ensure their patients were involved in developing their plan of care regarding hospice aide services in two of fourteen records reviewed (Records/Patients #10 and #14). This deficient practice has the potential to affect the provision of care for all the patients served by the provider. Findings included:Review of the document titled, “Patient Rights Policy,” dated January 2014, showed in part the patient had the right to: - Review and participate in the development of the plan of care and planning changes in the care; - Be informed in advance about the care to be furnished; - Be informed in advance of the disciplines that will furnish care and the frequency of visits proposed to be furnished; and- Be informed in advance of any change in the plan of care before the change is made. RECORD/PATIENT #10: Review of the clinical record showed the patient was admitted to hospice services on 08/30/2024 with a terminal diagnosis of Alzheimers Disease (a disease marked by progressive loss of mental capacity) with late onset and the patient transferred to a different hospice provider on 02/26/2025 per caregivers request. Review of an aide missed visit dated 02/03/2025, showed that the aide missed the visit due to illness. Review of the providers grievance log on 03/25/2025, showed that the patients caregiver made a complaint on 02/03/2025 that he/she was upset that an aide visit was not completed on 02/03/2025. The investigation results showed that the visit was missed due to illness and no other available home health aide (HHA). The resolution showed that the caregiver was unsatisfied and wanted to transfer the patient to another hospice. The provider failed to ensure that aide visits were completed as necessary to meet the needs of the patient. RECORD/PATIENT #14:Review of the clinical record showed the patient was admitted to hospice services on 07/24/2024 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient resided in their own home with the assistance of their spouse. Review of the provider’s grievance log on 08/05/2024, showed in part that:- The patient’s unidentified family member made a complaint on 08/05/2024 that he/she was unhappy because the aide visits were decreased to one time per week;- The investigation results showed that the HHA visits have decreased due to availability; - The resolution showed that the HHA was to be increased as soon as possible.”

“Based on policy review, record review, and interview, the hospice provider failed to assure the patient rights policy included the requirement for the hospice to inform the patient of the right to choose his/her attending physician. The hospice provider failed to assure the patient had their own physician involved in their medical care in collaboration with the hospice medical staff in one of fourteen applicable records reviewed (Record/Patient #1). This deficient practice has the potential to adversely affect all the provider’s patients. Findings included: Review of the provider’s policy titled, “Patient Rights Policy,” dated January 2014, failed to show that the patient has the right to choose their attending physician.Review of the provider’s policy titled, “Physician Services,” dated January 2014, showed in part the following:- The importance of a physician in directing the medical care is recognized;- The hospice’s medical director, in conjunction with the patient’s attending physician, are(is) responsible for the palliation and management of the terminal illness and conditions related to the terminal illness;- If the attending physician is unavailable, the medical director is responsible for meeting the medical needs of the patient; and- The attending physician will be sent written updates after each interdisciplinary meeting. Review of the provider’s policy titled, “Physician Orders/Plan of Care,” dated January 2014, showed in part that diagnostic and therapeutic orders will be obtained from the attending physician. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 08/09/2024 with a terminal diagnosis of Alzheimer’s disease with late onset (a disease marked by progressive loss of mental capacity). Related diagnoses included convulsions and severe protein-calorie malnutrition. The patient had a history of pressure ulcers (skin injury caused by unrelieved pressure) and resided in an assisted living facility (ALF). The patient did not have a pressure ulcer on admission.Review of the hospice wound care orders, with dates ranging from 10/31/2024 to 12/05/2024, showed the patient had a stage two pressure ulcer (a partial thickness loss of skin), and the orders were to cleanse wound, pat dry, apply Medihoney (brand, a medical grade honey used for wound healing) and foam border dressing. Change daily and as needed (PRN) when soiled. The hospice nurse was providing one time a week nursing visits, and the ALF staff were to change the dressing on the days that hospice did not make visits. Review of the ALF records showed a wound care order, dated 11/07/2024 through 12/04/2024, for Duoderm (brand, an adhesive dressing) to be applied to the wound and change every three days (the hospice orders were for Medihoney daily). The ALF record failed to show documentation that daily wound assessments and wound care were provided.Review of the skilled nurse note, dated 12/12/2024, showed in part the following:- The hospice case manager assessed the patient’s left hip and showed a stage three pressure ulcer (a full-thickness loss of skin) length 1.2 and width 1 (did not specify unit of measure), purulent drainage (thick drainage with odor or color present, commonly associated with infection), soft brown/black eschar (dead skin that is usually dry, tough, leathery, and black in color, tightly attached to a wound bed);- The treatment orders were to clean with wound cleanser, pat dry, apply hydrocolloid dressing (a wound dressing that forms a gel when exposed to water), and change every three days and as needed when soiled. The ALF staff was to provide all care in the absence of hospice; and- The registered nurse (RN) notified the ALF staff about the wound care orders obtained from the hospice medical director (not the patient’s attending physician) and was informed that the ALF staff would have to receive orders from their (ALF) doctor (the hospice record showed the facility’s physician was the patient’s attending physician).Review of the interdisciplinary group (IDG) meeting notes, dated 12/16/2024 through 12/29/2024, showed in part:- The patient’s left buttock wound reopened (no other description of the wound) and the treatment;- The frequency plan for skilled nursing (SN) visits ranged from two to four visits over the next 15 days. The patient had significant wound deterioration and the provider failed to increase the SN visit frequency (continued with once weekly visits); and- Updates to the plan of care were discussed with the facility (ALF) caregiver who verbalized understanding and agreement with the plan of care (there was no evidence the ALF was providing treatments).Review of the skilled nursing note, dated 12/26/2024, showed in part the following:- The RN discussed (with the ALF staff) that wound care needed to be done daily (the order was no longer daily, it was ordered for every three days and as needed, and no new orders were received for daily wound care); and- The attending physician was not notified of the wound deterioration.During an interview on 03/12/2025 at 10:35 AM, the case manager stated that he/she always went through the hospice medical director to get orders (the hospice medical director was not the patient’s attending physician). During an interview on 03/12/2025 at 8:55 AM, the director of clinical services (functioning as the registered nurse coordinator) stated that the orders were usually received from the hospice medical director unless another physician was elected. The hospice can get orders from any physician and relay to the facility, and it was up to the facility if they have other orders or different orders.During an interview on 03/12/2025 at 11:39 AM, the hospice medical director stated that he/she was not aware the ALF physician was the patient’s attending physician. If a patient had an attending physician, he/she would only be the back-up in the event the attending physician was not available. If there were conflicting orders it should have been brought to the hospice’s attention so they could communicate with each other and resolve the problem immediately. He/she could not recall any issues discussed regarding conflicting orders. Any issue brought to the hospice’s attention would be addressed. During an interview on 03/12/2025 at 11:45 AM, the ALF administrator stated that, if there was a new order, hospice could initiate the order with the ALF nurse and the ALF nurse always followed up with ALF physician (attending physician). He/she knew the hospice provider collaborated with hospice physician (hospice medical director), and the ALF consulted with the ALF physician (the attending physician).”

“Based on review of industry standards, policy review, record review, and interview, the hospice provider failed to ensure that pain assessments were completed in two of five full records reviewed (Records/Patients #4 and #5). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the providers policy titled, “;Initial Hospice Assessment,” dated 01/2014, showed in part that during the initial patient assessment the following information is relevant: an assessment of pain, including the origin, location, duration, severity and relief measures. Review of the providers policy titled, “;Ongoing Assessment,” dated 01/2014, showed in part that the nurse will assess each patient on each visit for pain, including the origin, location, duration, severity, and relief measures. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice services on 09/26/2024 with a terminal diagnosis of malignant neoplasm of the lower lobe, left bronchus, or lung (a cancer in the lung or airway of the lung). The patient resided in an assisted living facility (ALF). Review of the comprehensive assessment dated 09/26/2024, showed the patient had no complaints of pain and that the patient stated that pain was not a concern for him/her. Review of a skilled nurse (SN) visit note dated 01/02/2025, showed the following: - The patient complained of having a headache occasionally in the afternoon after leaving a bright light on in the room while trying to rest; - The patient denied pain and had no pain noted per non-verbal indicators; - The patient had orders for Tylenol (a medication used for mild pain) 325 milligrams (mg) two tablets twice a day scheduled, Tylenol Extra Strength 500 mg one tablet every six hours as needed for mild to moderate breakthrough pain rating 1 to 6 out of 10; Morphine 5 mg every four hours as needed for severe breakthrough pain rating 7 to 10 out of 10 or for air hunger; - The patient had not taken any as needed medication; and - The provider failed to ensure that the pain assessment included the duration of the patients pain, impact on the patients life, and factors that exacerbate or precipitate the pain. Review of a SN visit note dated 02/07/2025, showed the following: - The patient denied pain and had no pain noted per non-verbal indicators; - The patient complained of generalized pain and headaches; - The patient described the pain as aching; - The patient had orders for Tylenol (a medication used for mild pain) 325 milligrams (mg) two tablets twice a day scheduled, Tylenol Extra Strength 500 mg one tablet every six hours as needed for mild to moderate breakthrough pain rating 1 to 6 out of 10; Morphine 5 mg every four hours as needed for severe breakthrough pain rating 7 to 10 out of 10 or for air hunger; - The patient had not taken any as needed medication; and - The provider failed to ensure that the pain assessment included the duration of the patients pain, impact on the patients life, and factors that exacerbate or precipitate the pain. Review of a SN visit note dated 02/11/2025, showed the following: - The patient complained of pain to the lower back; - The patient described the pain as aching and rated the pain a 4 out of 10 on the pain scale; - The patient was withdrawn during conversation due to reported complaints of back pain; - The SN asked the ALF to provide an as needed dose of Tylenol and repositioned the patient; and - The provider failed to ensure that the pain assessment included the duration of the patients pain, impact on the patients life, and factors that exacerbate or precipitate the pain. Review of a SN visit note dated 02/28/2025, showed the following: - The patient denied pain and had no pain noted per non-verbal indicators; - The ALF had administered an as needed dose of Tylenol on 02/27/2025 for patient complaints of lower back pain; and - The SN failed to ensure that the pain assessment included the duration of the patients pain, the severity of the patients pain, impact on the patients life, and factors that exacerbate or precipitate the pain. Review of a SN visit note dated 03/25/2025, showed the following: - The patient complained of “;mild” pain to the lower back and left foot; - The patient described the pain as aching; - The SN requested the ALF to provide an as needed dose of Tylenol; and - The provider failed to ensure that the pain assessment included the duration of the patients pain, impact on the patients life, and factors that exacerbate or precipitate the pain. During an interview on 03/27/2025 at 11:50 AM, the registered nurse coordinator stated that pain should be assessed on the initial visit and then on each visit made. He/she stated that a pain assessment should be completed even if the patient did not complain of pain. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice services on 03/19/2025 with a terminal diagnosis of unspecified malignant neoplasm. The patient had secondary diagnoses of, but not limited to, Chronic Obstructive Pulmonary Disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe), hypertension (high blood pressure), and dementia (decline in mental capacity). The patient resided in a locked ward of a skilled nursing facility with 24-hour care provided. Review of the document titled, “Comprehensive Assessment,” dated 03/21/2025 showed in part that:- The assessment of the patient’s pain contained: * Identification that the patient was non-verbal, and pain would be rated using the PAINAD scale (Pain assessment in advance dementia; a tool used to assess pain in patients with advanced dementia who may have difficulty communicating their pain); * The patient had a pain rating of 0 on the PAINAD scale; * The patient was prescribed Dilaudid and morphine (both medications are strong opioid medications used to control severe pain); * The patient had taken no doses of breakthrough medications (indicating that the patient was taking pain medications on a routine basis; and- The patient/family pain management goals included: * To be pain free; * Maximum pain control with minimal symptoms; * Symptom management; and * Relieve pain/discomfort as much as possible even if that means no living as long; and- The comprehensive assessment failed to contain documentation of the origin, location, duration, severity and relief measures for the patient’s pain.”

“Based on policy review, record review, home visit observation, and interview, the hospice provider failed to ensure that a review of the patient’s medications was completed in two of five full records reviewed (Records/Patients #4 and #5). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the providers policy titled, “;Medications,” dated 01/2014 showed in part: - A medication list shall be maintained for each patient, which will be reviewed by an individual with education and training in drug management to ensure that the medications meet the patients needs; - If a patient resides in a nursing facility, medication management will be coordinated with the facility to assure there is compliance with federal and state regulations for both the hospice and the nursing facility; - Medication profiles shall be maintained for each patient; and - A periodic review and monitoring for appropriate medications and their use shall be documented and recommendations made to the physician as appropriate. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice services on 09/26/2024 with a terminal diagnosis of malignant neoplasm of the lower lobe, left bronchus, or lung (a cancer in the lung or airway of the lung). The patient resided in an assisted living facility (ALF). Review of the medication list from the provider, dated 03/24/2025, showed the following: - A medication order for Lorazepam (a medication used for anxiety) 0.5 milligrams (mg) one tablet every four hours PRN (pro re nata- as needed) and the ALF failed to include an order on the order summary report, dated 03/25/2025; - A medication order for Methenamine Hippurate (a medication used to prevent urinary tract infections) 1,000 mg one tablet daily and the ALF order on the order summary report, dated 03/25/2025, showed an order for one tablet twice daily; Review of the ALF order summary report, dated 03/25/2025, showed: - A medication order for Centrum Silver Women 50+ (a medication used as a vitamin supplement) one tablet daily and the provider failed to include the medication on the medication list, dated 03/24/2025; - A medication order for Hyoscyamine (a medication used for excessive secretions) 0.125 mg one tablet under the tongue every four hours PRN and the provider failed to include the medication on the medication list, dated 03/24/2025; and - A medication order for Risperidone (a medication used for behaviors) 0.5 mg one tablet at bedtime PRN and the provider failed to include the medication on the medication list, dated 03/24/2025. During an interview on 03/27/2025 beginning at 11:50 AM, the registered nurse coordinator stated that he/she expected medication reconciliation to be completed weekly or with any changes. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice services on 03/19/2025 with a terminal diagnosis of unspecified malignant primary neoplasm (cancer in an unspecified location). The patient had secondary diagnoses of, but not limited to, Chronic Obstructive Pulmonary Disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe), hypertension (high blood pressure), and dementia (decline in mental capacity). The patient resided in a locked ward of a skilled nursing facility with 24-hour care provided. During a home visit observation on 03/25/2025at 12:30 PM, a comparison of the provider’s medication profile (PMP) to the facility’s physician order (FPO) sheet showed the following discrepancies: - Atropine ophthalmic (a medication used to treat eye conditions and/or reduce airway secretions in terminally ill patients) solution the patient was to take: * Per the PMP the patient was to take two drops by mouth or sublingually (under the tongue) every four hours as needed for secretions; and* Per the FPO: One drop in both eyes every four hours as needed for eyes; - Bisacodyl (a stimulant laxative) suppository, the patient was to take: * Per the PMP: one suppository rectally daily as needed for constipation; and * Per the FPO: Insert one suppository rectally one time a day every three days for constipation; - The patient was to take Lorazepam: * Per the PMP: Oral concentrate 2mg/ml, give 0.5mg (0.25ml) by mouth or sublingually every four hours as needed for agitation/restlessness; * Per the FPO: Two orders were present. The first order beginning 03/18/2025 showed, “Lorazepam oral concentrate 1mg/0.ml, give 0.25ml by mouth every four hours as needed for anxiety.” The second order, beginning 03/22/2025, showed, “Lorazepam oral tablet 2mg. Give 0.5mg by mouth every four hours as needed for agitation/restlessness; - The patient was to take Morphine (an opioid pain medication used to treat moderate to severe pain): * Per the PMP: Morphine concentrate oral solution 100mg/5ml, give 5mg (0.25ml) by mouth or sublingually every four hours as needed for pain or air hunger; and * Per the FPO: Morphine oral solution 20mg/5ml, give 0.25ml by mouth every four hours as needed for pain; - The patient was to take Dilaudid (an opioid pain medication used to treat moderate to severe pain): * Per the PMP: Dilaudid 1mg/ml oral solution, give 1mg (1ml) by mouth every four hours for pain /sob; and * Per the FPO: Dilaudid 1ml/ml oral solution, give 1mg (1ml) by mouth every four hours as needed for pain/sob; - The patient was to use oxygen: * Per PMP: Oxygen via concentrator at two to four liters per minute per nasal cannula as needed for comfort/dyspnea/air hunger; and * Per FPO: Oxygen at two liters per minute per nasal cannula as needed for shortness of breath; and- The patient was to take Boost (a nutritional supplement): * The PMP failed to contain orders for Boost; and * Per the FPO: Boost two times per day.”

“Based on current survey findings, review of the director of clinical services (DCS; functioning as the registered nurse (RN) coordinator) job description, and interview, the hospice provider failed to ensure coordination of care was achieved to meet the patient’s and family’s needs. This deficient practice has the potential to affect the coordination of care for all of the provider’s patients. Findings included: The current survey findings showed the RN coordinator failed to effectively manage the coordination of patient care with other clinical providers resulting in noncompliance at an immediate jeopardy (IJ) level as follows: - §418.56 Interdisciplinary group, care planning, and coordination of services. An immediate jeopardy level for actual harm to one patient (Patient #1) and potential for future harm to other patients was identified during the survey; - The findings were confirmed as immediate jeopardy by the Centers for Medicare & Medicaid Services (CMS);- On 03/12/2025 at 4:54 PM, the administrator was informed verbally and in writing via the IJ Template, of the finding(s) identified at an immediate jeopardy level;- A formal written removal plan was submitted by the hospice provider prior to the survey exit;- This removal plan was reviewed by CMS, and it was determined on 03/13/2025 that a satisfactory removal plan had been initiated related to the immediate jeopardy findings; and- The condition level deficiency identified above remains as cited.During the complaint investigation and certification survey three additional condition-level deficiencies were identified at:- §418.56 Patient rights; - §418.64 Core services; and- §418.100 Organization and administration of services. Review of the document titled, “Job Title/Position: Director of Clinical Services,” dated January 2014, showed in part that the director of clinical services coordinates and oversees all direct and indirect patient services provided by clinical agency personnel; and ensures seamless service delivery by providing direct oversight of coordination of care with other clinical service providers. During the entrance interview performed on 3/24/2025 at 1:20 PM, the DCS stated that: - He/she functioned as the RN coordinator for the provider; and- His/her role was to oversee and coordinate clinical services.”

“Based on policy review, clinical record review, and interview, the provider failed to ensure the plan of care (POC) included interventions to manage symptoms related to the patient’s terminal illness and related conditions, in one of two revocation records reviewed (Record/Patient #8). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of provider’s policy titled, “Patient Plan of Care,” revised January 2014, showed in part:- Purpose - To provide continuity of care; and- The plan of care will include all services necessary for the palliation and management of the terminal illness and the related conditions, including interventions to manage pain and symptoms, and drug and treatment necessary to meet the needs of the patient. RECORD/PATIENT #8:Review of the clinical record showed the patient was admitted to hospice services on 11/18/2024 with a terminal diagnosis of brain cancer and secondary diagnosis of pressure sores (skin injury caused by unrelieved pressure) on the buttocks and genitalia. The patient resided at a friend’s home and his/her friend served as the patient’s primary caregiver (PCG). Review of the nursing visit note patient assessment, dated 01/14/2025, showed the following genitourinary (GU) findings:- A 16 French, 10 milliliter (ml) bulb (the size of the catheter tube/bulb) indwelling urinary catheter (a sterile tube placed in the bladder to drain urine); - Urine output- good;- Urine color – amber (normal = pale to light yellow);- Sediment /cloudy appearance (normal = clear);- Unusual odor- foul smelling (can indicate dehydration, urinary tract infection (UTI), certain foods, medications, or underlying health conditions like kidney problems or liver disease); and- A note that showed the nurse removed the leaking urinary catheter, replaced it with a new urinary catheter and obtained immediate output of 900 ml of amber urine. The skilled nurse (SN) note also showed the SN discussed concerns with the social worker (SW) that there was a potential need for long-term care facility placement due to the high level of care required by the patient. The plan was for the SN and SW to visit and assess the patient’s needs. Review of the nursing visit note patient assessment, dated 01/17/2025, showed the following GU assessment findings:- An indwelling urinary catheter in place, dependent to gravity, draining dark amber urine with 650 ml of output; and- The SN failed to document additional GU assessment findings during the visit. Review of the nursing visit note / psychosocial visit note, dated 01/21/2025, showed the following: -The purpose of the visit was to discuss a respite stay for the patient;- The patient rated their pain as a 10/10 (based on a zero (0) to 10 pain scale in which 0 indicated no pain and 10 indicated the worst possible pain);- The patient was hollering out during the visit and wanted to go to the hospital due to genital pain from the urinary catheter and the wound on his/her genitalia; and- The patient revocated hospice services and was transported to the hospital by emergency medical services (EMS) on 01/21/2025.Review of the POC update/ Interdisciplinary Group (IDG) note, dated 01/21/2025, showed the provider failed to have interventions in place to assess for signs and symptoms of infection related to the patient’s indwelling urinary catheter.Review of the patient’s hospital emergency department records dated 01/21/2025, showed the following diagnoses: -Urinary tract infection; and- Leukocytosis (a condition characterized by an elevated white blood cell (WBC) count. Elevated WBCs are often a sign of an infection). During an interview on 03/25/2025 at 12:30 PM, the registered nurse coordinator stated that the nurse should have informed the the patient’s physician of the 01/14/2024 genitourinary assessment findings and symptoms.”

“Based on policy review, record review, and interview, the provider failed to ensure that the interdisciplinary group (IDG) maintained responsibility for directing, coordinating, and supervising the care and services provided when the registered nurse failed to properly assess and provide wound care as ordered resulting in hospitalization, in one out of five full records reviewed (Record/Patient #1). This deficient practice has the potential to adversely affect all the provider’s patients. Findings included:Review of the provider’s policy titled, “Hospice Interdisciplinary Group,” dated January 2014, showed in part the following:- The hospice Interdisciplinary Group (IDG) will work together to meet the physical, emotional, and spiritual needs of hospice patients and their families facing terminal illness and bereavement;- For each patient, a registered hospice nurse who is a member of the IDG, will act as the patient’s care manager. The registered nurse (RN) will provide coordination of care and ensure continuous assessment of each patient and family’s needs and implementation of the plan of care (POC);- The hospice care team will review and update the patient care plan, at least bi-weekly, at the established patient care plan meeting;- The hospice care team will also be responsible for providing or supervising hospice care and services;- A RN will be assigned to each patient as the case manager. The patient care coordinator or director of clinical services will serve as the coordinator of the hospice IDG; - The IDG will maintain a system of communication to ensure that patient care and services are provided in accordance with the POC and are based on assessments and family needs; and- The IDG will maintain responsibility for directing, coordinating, and supervising the care and services provided. They will provide for and ensure the ongoing and sharing of information between all disciplines providing care in all settings, including sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. Review of the provider’s policy titled, “Physician Services,” dated January 2014, showed in part the following:- The importance of a physician in directing the medical care is recognized;- The hospice’s medical director in conjunction with the patient’s attending physician, are responsible for the palliation and management of the terminal illness and conditions related to the terminal illness;- If the attending physician is unavailable, the medical director is responsible for meeting the medical needs of the patient; and- The attending physician will be sent written updates after each interdisciplinary meeting. Review of the provider’s policy titled, “Ongoing Assessment,” dated January 2014, showed in part the following:- The nurse will assess each patient on each visit for alteration of skin integrity; and- Wounds should be viewed/documented every visit unless the RN case manager has documented a successful return demonstration of the wound care by an authorized person, in which case the RN case manager must view the wound minimally one time per week. Good nursing care should guide the judicious use of the above explanation. Review of the provider’s policy titled, “Physician Orders/Plan of Care,” dated January 2014, showed in part that diagnostic and therapeutic orders will be obtained from the attending physician. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 08/09/2024 with a terminal diagnosis of Alzheimer’s disease with late onset (a disease marked by progressive loss of mental capacity). Related diagnoses included convulsions and severe protein-calorie malnutrition. The patient had a history of pressure ulcers (skin injury caused by unrelieved pressure) and resided in an assisted living facility (ALF). The patient did not have a pressure ulcer on admission. Review of the hospice wound care orders, with dates ranging from 10/31/2024 through 12/05/2024, showed the patient had a stage two pressure ulcer (a partial thickness loss of skin), and the orders were to cleanse wound, pat dry, apply Medihoney (brand, a medical grade honey used for wound healing) and foam border dressing. Change daily and as needed (PRN) when soiled. The hospice nurse was providing one time a week nursing visits, and the ALF staff were to change the dressing on the days that hospice did not make visits. Review of the ALF records showed a wound care order dated 11/07/2024 through 12/04/2024, for Duoderm (brand, an adhesive dressing) to be applied to the wound and changed every three days (the hospice orders were for Medihoney daily). The ALF documentation failed to show documentation of daily wound assessments and wound care being provided. The hospice provider failed to ensure that the patient’s care was being coordinated as ordered. Review of a comprehensive assessment dated 11/26/2024, the patient had a stage two wound to the left buttock, measured “1 length and 1 width” (did not specify a unit of measurement) with scant serous drainage (clear watery drainage) and the surrounding tissue was pink. Review of the skilled nurse (SN) visit note, dated 12/05/2024, showed the hospice RN discussed with the ALF staff that there was redness to the patient’s “bottom,” the left buttock wound was healed and no longer required treatment. Education was provided on the use of barrier cream to avoid skin breakdown. The RN failed to assess the patient’s left hip from 11/27/2024 to 12/11/2025 and received orders to discontinue the wound care on 12/05/2024 without assessing the wound to confirm that the wound was healed.Review of the SN note, dated 12/12/2024 (15 days since the last skin assessment), showed in part the following:- The hospice case manager assessed the patient’s left hip and showed the patient developed a stage three pressure ulcer (a full-thickness loss of skin) length 1.2 and width 1 (did not specify unit of measurement), purulent drainage (thick drainage with odor or color present, commonly associated with infection), soft brown/black eschar (dead skin that is usually dry, tough, leathery, and black in color, tightly attached to a wound bed);- The treatment orders were to clean with wound cleanser, pat dry, apply hydrocolloid dressing (a dressing that forms a gel when exposed to water), and change every three days and as needed when soiled. The facility was to provide all care in the absence of hospice;- The RN notified the ALF staff about the wound care orders obtained from the hospice medical director and was informed that the ALF staff would have to receive orders from their (ALF) doctor (the hospice record showed the facility’s physician was the patient’s attending physician); and- Review of a picture showed the wound located on the left hip/buttocks area. The wound bed was dark brown/black in color. The wound edges were raised and reddened. (The wound presented as an unstageable wound (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it was obscured by slough (dead tissue in the wound bed) or eschar in the picture.) Review of the hospice facility nursing note that was left in the hospice binder at the ALF, dated 12/12/2025, showed documentation that the patient’s skin was warm to touch and intact. (The documentation was not consistent with the hospice note regarding the stage three pressure ulcer).Review of the ALF medication and treatment record for 12/2024 failed to show an order for wound treatment (the hospice failed to coordinate and supervise care by failing to ensure the ALF was providing care as ordered). Review of the IDG notes, dated 12/16/2024 through 12/29/2024, showed in part:- The patient’s wound to the left buttock reopened (no other description of the wound) and the treatment;- The frequency plan for SN visits ranged from two to four visits over the next 15 days. The patient had significant wound deterioration, and the provider failed to increase the SN visit frequency (continued with once weekly visits); and- Updates to the plan of care were discussed with the facility (ALF) caregiver who verbalized understanding and agreement with the plan of care (there was no evidence the ALF was providing treatments). Review of the SN note, dated 12/26/2024, showed in part the following:- Skin: left buttocks stage three pressure ulcer showed length 1.4, width 1.4 (there was no unit of measurement);- Observation of a picture of the wound included in the note, showed the wound bed was dark brown/black in color. The wound edges were reddened, and the skin peeled off in places. The skin surrounding the wound edges was reddened and appear inflamed. (The wound presented as an unstageable wound in the picture);- The RN discussed (with the ALF staff) that wound care needed to be done daily (the order was no longer daily, it was ordered for every three days and as needed, and no new orders were received for daily wound care); and - The attending physician was not notified of the wound deterioration. Review of the discharge summary, dated 12/29/2024, showed the reason for discharge was the patient moved out of service area. The summary of care showed the patient received weekly assessment to help manage symptoms including skin breakdown and pain. Review of the hospital record showed in part the following:- The patient was admitted on 12/29/2024 for necrotic wound to left hip;- “The son is at the bedside who states that he was in town visiting and noticed that [she] had a chronic wound to the left hip and the dressing had not been changed in three weeks”;- “States that [he] (patient’s son) noticed a foul-smelling odor from the wound. Reports noticing area of necrosis, redness, and some drainage”;- The patient’s son stated they decided to revoke hospice and presented here (ER) for evaluation of the wound;- On arrival the patient had a temp of 100.8;- Large decubitus ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) noted to the left hip with area of dry gangrene (type of tissue death (necrosis) that occurs when blood flow to an area of the body is severely reduced or cut off) and erythema (redness of the skin) and foul-smelling odor; - The admitting diagnosis was necrotizing fasciitis (a serious bacterial infection that destroys tissue under the skin) and pressure injury of skin with infection;- UA (urinalysis) was significant for infection;- Preliminary wound culture showed few gram-positive cocci and rare gram-negative bacilli (suggest a bacterial wound infection);- CT (computed tomography scan - a medical imaging procedure) of the abdomen/pelvis showed a large left decubitus ulceration and ulceration extending into the ischium (bone in the pelvis that forms the lower and back part of the hip bone), and measured 6.4 x 3.6 x 5.5 cm (centimeter) could represent abscess (localized collection of bus that forms in an infected area of the body. Soft tissue gas is overlying the collection and is either due to disruption of the skin or represents gangrenous infection. Surgical evaluation was recommended (The last hospice assessment on 12/26/2024, showed a stage three pressure ulcer to the left buttock, length 1.4 and width 1.4 and there was no unit of measurement);- Assessment/plan was large left ischial decubitus ulcer with possible abscess formation and soft tissue gas, concerning for NSTI (necrotizing soft tissue infection, a rare but serious bacterial infection that causes the rapid death and destruction of skin, muscle, and other soft tissues;- “There was a large amount of stool noted throughout the colon and rectum, will discuss with general surgery. Keep NPO (nothing by mouth) for possible debridement (the removal of damaged tissue from a wound)”;- Borderline sepsis (a life-threatening complication of an infection);- Abnormal UA (Infection in the urinary tract); - “Social worker in context of concern for possible neglect”; and- Severe dementia with possible encephalopathy (a broad term for any brain disease that alters brain function or structure, causes include infection, tumor, and stroke) acute likely in context of infection/ borderline sepsis. Review of the hospital general surgery consult note, dated 12/30/2024, showed the patient had past medical history was significant for dementia, seizure, malnutrition who was previously on hospice that was rescinded. The patient presented to the hospital for an ischial ulcer that has been progressively worsened. It is malodorous but no drainage. Her family brought her to the hospital as they would like to be evaluated and debrided. The CT showed a large infected ischial ulcer. Review of the hospital operative report dated 12/30/2024, showed in part the following:- Procedure: excisional (removal by surgical cutting) debridement of left ischial ulcer;- Pre-Op (preoperative) wound measurements: 4 x 6 cm;- Post-op (postoperative) wound measurements: 8 x 6 x 3 cm;- Total area excised: 48 cm;- Skin, subcutaneous tissue, and muscle excised; and- A wound vac (a medical device that uses suction to promote wound healing) and changed every three days. Review of the hospital in-patient discharge summary, dated 01/08/2025, showed in part the following:- Hospital length of stay: 9 (nine) days;- Hospital problems/diagnosis: severe protein-calorie malnutrition and pressure injury of skin with infection; - Reason for hospitalization: wound;- They were waiting for the MRI (magnetic resonance imaging - a medical imaging technique) results to determine if the patient had osteomyelitis (inflammation of bone caused by infection);- The patient had a wound vac, IV (intravenous) antibiotics, and I and D (incision and drainage, drain pus from and abscess), and excisional debridement of left ischial wound during his/her stay; and- The patient was discharged on hospice services with a different hospice provider. During an interview on 03/11/2025 at 11:44 AM, the case manager stated that he/she was the nurse that that made visits to patient #1. The day he/she visited the patient, the patient (12/12/2024) was up in a Broda chair (a type of specialty wheeled chair) so he/she did not assess the patient’s skin. The ALF nurse stated that he/she had already assessed the skin and there was no wound. Then the hospice aide sent a picture that the wound was open, the case manager called the ALF nurse and gave the treatment orders, and the ALF nurse stated that he/she would have to get his/her own orders. He/she never takes another nurse’s word for an assessment. The patient went to the hospital due to the patient’s daughter decided to get aggressive treatment per triage. He/she only asked the ALF if there were any patient changes, he/she does not look at the medication or treatment administration records. The ALF did not have orders for the Medihoney and there was no evidence of daily dressing changes being completed as ordered. During an interview on 03/12/2025 at 8:55 AM, the director of clinical services (RN coordinator) stated that:- Orders were usually received from the hospice medical director unless another physician was elected;- Any orders given to the facilities were placed in the red binders at the facility;- Some places prefer verbal orders but usually a written order was given to the facility nurse;- The physician orders should match, and hospice should be educating staff if this was not happening, verbally update the staff and let the physician know (if orders do not match); - The facility staff communicated with the hospice physician through the hospice nurse, who communicated with the hospice physician through IDG, teams, and phone calls;- The IDG note that showed two or four visits were for the two-week period and they provided one visit a week;- He/she thought the education to the ALF was effective and the wound care orders were provided;- They do not have access to the ALF’s documentation, medication and treatment administration record and they had trouble when giving orders to a particular nurse at the ALF;- The wound measurements were in cm, and staff were to measure weekly;- The case manager educated the ALF on the new orders, and they did not let the hospice nurse know they had different orders and how would hospice know that;- The hospice can get orders from any physician and relay to the facility, and it was up to the facility if they had other orders or different orders;- They provided wound treatment for comfort and if the patient had not gone to the hospital they would have continued to treat the wound;- “Our (hospice) orders are their (ALF) orders, when the wound declined, [he/she] (the case manager) was educating on their (hospice) orders”; - The facility was to notify the hospice of any changes in the patient’s condition; and- During the IDG meeting on 12/12/2024, they discussed the patient’s wound while showing the picture of the wound on a screen but they did not document the specific discussion. During an interview on 03/12/2025 at 10:35 AM, the case manager stated that:- He/she was not aware the hospice and ALF did not have the same orders;- The ALF nurse was doing daily dressing changes (the ALF record failed to show daily dressing changes); - He/she always goes through the hospice medical director to get orders (the hospice medical director was not the patient’s attending physician);- Sometimes he/she would go to the ALF and the wound care was not done. If wound care was not completed, he/she would educate the ALF nurse (the ALF record did not show daily wound care); and- He/she should have increased visits, but the facility was to provide all the care. During an interview on 03/12/2025, the hospice medical director stated that he/she was not aware the ALF had an attending physician. If a patient had an attending physician, he/she would only be the back-up in the event the attending physician was not available. If there were conflicting orders it should have been brought to the hospice’s attention so they could communicate with each other and resolve the problem immediately. He/she could not recall any issues discussed regarding conflicting orders. Any issue brought to the hospice’s attention would be addressed. During an interview on 03/12/2025 at 11:45 AM, the ALF administrator stated that::- The ALF staff and hospice nurse were supposed to collaborate and call the family together;- If there was a new order, hospice could initiate the order with the ALF nurse and the ALF nurse always followed up with their physician (attending physician);- He/she knew the hospice provider collaborated with their physician (hospice medical director), and the (ALF) consulted with theirs (the attending physician);- If there were any discrepancies, they would let their physician know;- The hospice nurse did collaborate with the RCF nurse; and- What was in the hospice chart was different than the ALF chart and the date the order changed (for wound care on 12/12/2024) was not in the hospice nurse note that was left at the ALF and the hospice nurse did not notify the ALF nurse and that was “when the trouble started”. During an interview on 03/17/2025 at 12:33 PM, the ALF administrator stated that the hospice staff always wanted a copy of their medical records to put in their hospice records. They can look at medical information anytime they want to, and “how else are you supposed to coordinate care if you don’t share medical records/information or look at the chart.”During an interview on 03/17/2025 at 1:22 PM, the patient’s family member stated that:- Hospice never informed him/her of the patient’s wound;- He/she was told last fall by the ALF that the patient had a wound, and the wound was very small and not infected;- He/she had a poor sense of smell, and his/her sibling was visiting and was alerted about the wound by the odor coming from the wound;- The day after the patient was hospitalized the hospice nurse called and stated that he/she was really surprised this had happened and the last time he/she saw the wound it was not open and not infected, and he/she was sorry;- He/she did not know how the hospice nurse could say that since they had video recordings showing the hospice nurse and hospice aide looking at the wound;- The patient had surgery to cut out the necrotic tissue and then the patient had a wound vac placed and had IV antibiotics;- The patient was on the wound vac for a few days and the hospital medical staff said it was not doing enough and removed it, a few days later they did an MRI which showed the infection had spread to the bone;- The wound care nurse stated that the probability of the patient’s recovery was very low, they could put the patient on six weeks of IV antibiotics and go to a skilled nursing facility and the family decided not to put the patient through that and put the patient back on hospice;- The patient was moved to a hospice house where he/she lived for another two to three weeks and died on 01/26/2025; and- The family member stated to the ALF that if the patient went to the hospital and died from the (wound), “this is a stupid way to die”, they had to put the patient through surgery to remove the “stink” from the wound so he/she “could have [his/her] dignity”. He/she felt the patient could have lived a little longer if he/she did not have to endure the surgery.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure the nursing needs of the patient were met in two of three revocation records reviewed (Records/Patients #1 and #8). This deficient practice has the potential to affect all the patients served by the hospice provider. Findings included: Review of provider’s policy titled, “Patient Plan of Care,” revised January 2014, showed in part:- Purpose - To provide continuity of care; and- The plan of care will include all services necessary for the palliation and management of the terminal illness and the related conditions, including interventions to manage pain and symptoms, and drug and treatment necessary to meet the needs of the patient. RECORD/PATIENT #8:Review of the clinical record showed the patient was admitted to hospice services on 11/18/2024 with a terminal diagnosis of brain cancer and a secondary diagnosis of pressure sores (skin injury caused by unrelieved pressure) on the buttocks and genitalia. The patient resided at a friend’s home and his/her friend served as the patient’s primary caregiver (PCG). Review of the nursing visit note patient assessment, dated 01/14/2025, showed the following genitourinary (GU) findings:- The patient had a 16 French, 10 milliliter (ml) bulb, indwelling urinary catheter (a sterile tube placed in the bladder to drain urine); - Urine output - good;- Urine color – amber;- Sediment /cloudy appearance;- Unusual odor- foul smelling; and- Note – removed leaking urinary catheter and replaced with a new urinary catheter. Obtained immediate output of 900 milliliters (ml) of amber urine. The skilled nurse (SN) note also showed the SN discussed concerns with the social worker (SW) that there was a potential need for long-term care facility placement due to the high level of care required by the patient. The plan was for the SN and SW to visit and assess the patient’s needs. Review of the nursing visit note patient assessment, dated 01/17/2025, showed the following GU assessment findings:- An indwelling urinary catheter in place, dependent to gravity, draining dark amber urine with 650 ml of output; and - The SN failed to document additional GU assessment findings.Review of the nursing visit note / psychosocial visit note, dated 01/21/2025, showed the following: -The purpose of the visit was to discuss a respite stay for the patient;- The patient rated their pain as a 10/10 (based on a zero (0) to 10 pain scale in which 0 indicated no pain and 10 indicated the worst possible pain); - The patient was hollering out during the visit and wanted to go to the hospital due to genital pain from the urinary catheter and the wound on his/her genitalia; and- The patient revocated hospice services and was transported to the hospital by emergency medical services (EMS) on 01/21/2025. Review of the patient’s hospital emergency department records, dated 01/21/2025, showed the following diagnoses: -Urinary tract infection; and- Leukocytosis (a condition characterized by an elevated white blood cell (WBC) count. Elevated WBCs are often a sign of infection). During an interview on 03/25/2025 at 12:30 PM, the registered nurse coordinator stated that the nurse should have informed the the patient’s physician of the 01/14/2024 genitourinary assessment findings and symptoms. RECORD/PATIENT #1 Review of the medical record showed the patient was admitted to hospice on 08/09/2024 with a terminal diagnosis of Alzheimer’s disease with late onset. Related diagnosis included convulsions and severe protein-calorie malnutrition. The patient had a history of pressure ulcers skin injury (skin injury caused by unrelieved pressure) and resided in an assisted living facility (ALF). The patient did not have a pressure ulcer on admission. Review of the hospice wound care orders from 10/31/2024 through 12/05/2024 showed the patient had a stage two pressure ulcer (a partial thickness loss of skin), and the orders were to cleanse wound, pat dry, apply Medi honey (promote a moist wound environment, aid in autolytic debridement, and combat bacteria, ultimately supporting the natural healing process) and foam boarder dressing. Change daily and PRN when soiled. The hospice nurse was providing one time a week nursing visits, and the ALF staff were to change the dressing on the days that hospice did not make visits. Review of the ALF records showed a wound care order dated November 7, 2024, through December 4, 2024, for Duoderm (hydrocolloid dressing) to be applied to the wound and change every 3 days (the hospice orders were for Medi honey daily). The ALF record failed to show documentation of daily wound assessments and wound care being provided.Review of the SN visit note on 12/05/2024 showed, documentation that the hospice RN discussed with the ALF staff that there was redness to the patient’s “bottom,” the left buttock wound was healed and no longer required treatment. Education was provided on the use of barrier cream to avoid skin breakdown.The RN failed to assess the patient’s left hip from 11/27/2024 to 12/11/2025 and received orders to discontinue the wound care on 12/05/2024 without assessing the wound to confirm that the wound was healed.Review of the IDG 12/16/2024 through 12/29/2024 showed in part:- The patient’s wound to the left buttock reopened (no other description of the wound) and the treatment;- Nursing planned visit frequencies showed skilled nurse visits ranging from 2 to 4 visits throughout the next 15 days (The patient had significant wound deterioration and the hospice staff continued to provide the least amount of skilled nurse visits by only seeing the patient one time a week);- Updates to the plan of care were discussed with the facility (ALF) caregiver who verbalized understanding and agreement with the plan of care (there was no evidence the ALF was providing treatments); and- The attending physician was consulted and verbalized agreement with the plan of care (there was no documentation to show that the IDG team consulted with the attending physician regarding this plan of care). Review of the skilled nursing note, dated 12/26/2024, showed in part the following:- Skin: left buttocks stage three pressure ulcer showed length 1.4, width 1.4 (there was no unit of measurement);- Observation of a picture of the wound included in the note, showed the wound bed dark brown/black in color. The wound edges reddened, and the skin peeled off in places. The skin surrounding the wound edges reddened and appear inflamed. (The wound presented as an unstageable wound in the picture);- The RN discussed that wound care needed to be done daily (the order was no longer daily, it was ordered for every three days and as needed, and no new orders were received for daily wound care); and- The attending physician was not notified of the wound deterioration. Review of the hospital record showed in part the following:- The patient was admitted on 12/29/2024 for necrotic wound to left hip;- “The patient’s son was in town visiting and noticed the patient had a chronic wound to the left hip and the dressing had not been changed in three weeks”;- “The patient’s son noticed a foul-smelling odor from the wound and reported noticing area of necrosis, redness, and some drainage”;- The patient’s son stated they decided to revoke hospice and presented here (ER) for evaluation of the wound;- On arrival the patient had a temp of 100.8;- Large decubitus ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) noted to the left hip with area of dry gangrene (type of tissue death (necrosis) that occurs when blood flow to an area of the body is severely reduced or cut off) and erythema (redness of the skin) and foul-smelling odor; - The admitting diagnosis was necrotizing fasciitis (a serious bacterial infection that destroys tissue under the skin) and pressure injury of skin with infection;- UA (urinalysis) was significant for infection;- Preliminary wound culture showed few gram-positive cocci and rare gram-negative bacilli (suggest a bacterial wound infection);- CT of the abdomen/pelvis showed a large left decubitus ulceration and ulceration extending into the ischium (bone in the pelvis that forms the lower and back part of the hip bone), and measured 6.4 x 3.6 x 5.5 cm (centimeter) could represent abscess (localized collection of bus that forms in an infected area of the body. Soft tissue gas is overlying the collection and is either due to disruption of the skin or represents gangrenous infection. Surgical evaluation was recommended (The last hospice assessment on 12/26/2024, showed a stage three pressure ulcer to the left buttock, length 1.4 and width 1.4 and there was no unit of measurement);- Assessment/plan was large left ischial decubitus ulcer with possible abscess formation and soft tissue gas, concerning for NSTI (necrotizing soft tissue infection, a rare but serious bacterial infection that causes the rapid death and destruction of skin, muscle, and other soft tissues;- “There was a large amount of stool noted throughout the colon and rectum, will discuss with general surgery. Keep NPO (nothing by mouth) for possible debridement (the removal of damaged tissue from a wound)”;- Borderline sepsis (a life-threatening complication of an infection);- Abnormal UA (Infection in the urinary tract);- “Social worker in context of concern for possible neglect”; and- Severe dementia with possible encephalopathy (a broad term for any brain disease that alters brain function or structure, causes include infection, tumor, and stroke) acute likely in context of infection/ borderline sepsis. During an interview on 03/11/2025 at 11:44 AM, the case manager stated that he/she was the nurse that that made visits to patient #1. The day he/she visited patient (12/12/2024), the patient was up in a Brada Chair (a chair or wheelchair that provides comfort, support, and mobility) so he/she did not assess the patient’s skin. The ALF nurse said he/she had already assessed the skin and there was no wound. Then the hospice aide sent a picture that the wound was open, the case manager called the ALF nurse and gave the treatment orders, and the ALF nurse said he/she would have to get his/her own orders. He/she never takes another nurse’s word for an assessment. He/she does not look at the ALF medication or treatment administration records, he/she only asks the ALF staff if there have been any patient changes. The patient went to the hospital due to the patient’s daughter deciding to get aggressive treatment per triage (The ALF did not have orders for the Medi-honey and there was no evidence of daily dressing changes being completed as ordered). During an interview on 03/12/2025 at 8:55 AM, the director of clinical services stated the following:- Orders were usually received from the hospice medical director unless another physician was elected;- Any orders given to the facilities were placed in the red binders at the facility;- The physician orders should match, hospice should be educating staff if this was not happening, verbally update the staff and let the physician know (if orders do not match);- The ALF staff communicated with the hospice physician through the hospice nurse, who communicate with the hospice physician through IDG, teams, and phone calls;- He/she thought the education to the ALF was effective and that the wound care orders were provided;- They do not have access to the ALF’s documentation, medication and treatment administration record and have trouble when giving orders to a particular nurse at the ALF;- The wound measurements (missing the unit of measurement) were in cm and staff were to measure weekly;- The case manager educated the ALF on the new orders, and they did not let the hospice nurse know they had different orders and how would hospice know that;- The hospice can get orders from any physician and relay to the facility, and it was up to the facility if they have other orders or different orders;- They provided wound treatment for comfort and if the patient had not gone to the hospital they would have continued to treat the wound (Treatments were not being completed as ordered);- “The hospice orders were the ALF orders and when the wound declined the case manager was educating on the hospice orders”;- The facility was to notify the hospice of any changes in the patient’s condition; and- During the IDG meeting on 12/12/2024 they discussed the patient’s wound while showing the picture of the wound on a screen, but they did not document the specific discussion. During an interview on 03/12/2025 at 10:35 AM, the case manager stated that:- He/she was not aware the hospice and ALF did not have the same orders;- The ALF nurse was doing daily dressing changes (the ALF record failed to show daily dressing changes);- He/she always goes through the hospice medical director to get orders (the hospice medical director was not the patient’s attending physician);- Sometimes he/she would go to the ALF and the wound care was not done and he/she would educate the ALF nurse (the ALF record did not show daily wound care); and- He/she should have increased visits, but the facility was to provide all the care. During an interview on 03/12/2025, the hospice medical director stated that he/she was not aware the ALF had an attending physician. If a patient had an attending physician, he/she would only be the back-up in the event the attending physician was not available. If there were conflicting orders it should have been brought to the hospice’s attention so they could communicate with each other and resolve the problem immediately. He/she could not recall any issues discussed regarding conflicting orders. Any issue brought to the hospice’s attention will be addressed. During an interview on 03/12/2025 at 11:45 AM the ALF (assisted living facility) administrator stated that:- The ALF staff and hospice nurse were supposed to collaborate and call the family together;- If there was a new order, hospice can initiate the order with the ALF nurse and the ALF nurse always follows up with their physician (attending physician);- He/she knew the hospice provider collaborated with their physician (hospice medical director), and the (ALF) consulted with theirs (the attending physician);- If there were any discrepancies, they would let their physician know;- The hospice nurse did collaborate with the ALF nurse; and- What was in the hospice chart was different than the ALF chart and the date the order changed (for wound care on 12/12/2024) was not in the hospice nurse note that was left at the ALF and the hospice nurse did not notify the ALF nurse and that was “when the trouble started”. During an interview on 03/17/2025 at 12:33 PM, the ALF administrator stated that the hospice staff always want a copy of their medical records to put in their hospice records. They can look at medical information anytime they want to, and “how else are you supposed to coordinate care if you don’t share medical records/information or look at the chart”.During an interview on 03/17/2025 at 1:22 PM, the patient’s family member stated that hospice never informed him/her of the patient’s wound; RECORD/PATIENT #1: Review of the medical record showed the patient was admitted to hospice on 08/09/2024 with a terminal diagnosis of Alzheimer’s disease with late onset (a disease marked by progressive loss of mental capacity). Related diagnoses included convulsions and severe protein-calorie malnutrition. The patient had a history of pressure ulcers (skin injury caused by unrelieved pressure) and resided in an assisted living facility (ALF). The patient did not have a pressure ulcer on admission. Review of the hospice wound care orders, with dates ranging from 10/31/2024 through 12/05/2024, showed the patient had a stage two pressure ulcer (a partial thickness loss of skin), and the orders were to cleanse wound, pat dry, apply Medihoney (brand - a medical grade honey used for wound healing) and foam border dressing. Change daily and as needed (PRN) when soiled. The hospice nurse was providing one time a week nursing visits, and the ALF staff were to change the dressing on the days that hospice did not make visits. Review of the ALF records showed a wound care order, dated 11/07/2024 through 12/04/2024, for Duoderm (brand, an adhesive dressing) to be applied to the wound and change every three days (the hospice orders were for Medihoney daily). The ALF record failed to show documentation of daily wound assessments and wound care provided.Review of the SN visit note, dated 12/05/2024, showed documentation that the hospice RN discussed with the ALF staff that there was redness to the patient’s “bottom,” the left buttock wound was healed and no longer required treatment. Education was provided on the use of barrier cream to avoid skin breakdown.The RN failed to assess the patient’s left hip from 11/27/2024 to 12/11/2025 and received orders to discontinue the wound care on 12/05/2024 without assessing the wound to confirm that the wound was healed.Review of the IDG notes, dated 12/16/2024 through 12/29/2024, showed in part:- The patient’s wound to the left buttock reopened (no other description of the wound) and the treatment;- The frequency plan for SN visits ranged from two to four visits over the next 15 days. The patient had significant wound deterioration and the provider failed to increase the SN visit frequency (continued with once weekly visits ;- Updates to the plan of care were discussed with the facility (ALF) caregiver who verbalized understanding and agreement with the plan of care (there was no evidence the ALF was providing treatments); and- The attending physician was consulted and verbalized agreement with the plan of care (there was no documentation to show that the IDG team consulted with the attending physician regarding this plan of care). Review of the skilled nursing note, dated 12/26/2024, showed in part the following:- Skin: left buttocks stage three pressure ulcer showed length 1.4, width 1.4 (there was no unit of measurement);- Observation of a picture of the wound included in the note, showed the wound bed was dark brown/black in color. The wound edges were reddened, and the skin was peeled off in places. The skin surrounding the wound edges was reddened and appear inflamed. (The wound presented as an unstageable wound in the picture: (a pressure sore that is covered by dead tissue making it impossible to determine the severity) );- The RN discussed that wound care needed to be done daily (the order was no longer daily, it was ordered for every three days and as needed, and no new orders were received for daily wound care); and- The attending physician was not notified of the wound deterioration. Review of the hospital record showed in part the following:- The patient was admitted on 12/29/2024 for necrotic wound to left hip;- “The patient’s son was in town visiting and noticed the patient had a chronic wound to the left hip and the dressing had not been changed in three weeks”;- “The patient’s son noticed a foul-smelling odor from the wound and reported noticing area of necrosis, redness, and some drainage”;- The patient’s son stated they decided to revoke hospice and presented here (ER) for evaluation of the wound;- On arrival the patient had a temp of 100.8;- Large decubitus ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) noted to the left hip with area of dry gangrene (type of tissue death (necrosis) that occurs when blood flow to an area of the body is severely reduced or cut off) and erythema (redness of the skin) and foul-smelling odor; - The admitting diagnosis was necrotizing fasciitis (a serious bacterial infection that destroys tissue under the skin) and pressure injury of skin with infection;- UA (urinalysis) was significant for infection;- Preliminary wound culture showed few gram-positive cocci and rare gram-negative bacilli (suggest a bacterial wound infection);- CT of the abdomen/pelvis showed a large left decubitus ulceration and ulceration extending into the ischium (bone in the pelvis that forms the lower and back part of the hip bone), and measured 6.4 x 3.6 x 5.5 cm (centimeter) could represent abscess (localized collection of bus that forms in an infected area of the body. Soft tissue gas is overlying the collection and is either due to disruption of the skin or represents gangrenous infection. Surgical evaluation was recommended (The last hospice assessment on 12/26/2024, showed a stage three pressure ulcer to the left buttock, length 1.4 and width 1.4 and there was no unit of measurement);- Assessment/plan was large left ischial decubitus ulcer with possible abscess formation and soft tissue gas, concerning for NSTI (necrotizing soft tissue infection, a rare but serious bacterial infection that causes the rapid death and destruction of skin, muscle, and other soft tissues;- “There was a large amount of stool noted throughout the colon and rectum, will discuss with general surgery. Keep NPO (nothing by mouth) for possible debridement (the removal of damaged tissue from a wound)”;- Borderline sepsis (a life-threatening complication of an infection);- Abnormal UA (Infection in the urinary tract);- “Social worker in context of concern for possible neglect”; and- Severe dementia with possible encephalopathy (a broad term for any brain disease that alters brain function or structure, causes include infection, tumor, and stroke) acute likely in context of infection/ borderline sepsis. During an interview on 03/11/2025 at 11:44 AM, the case manager stated that he/she was the nurse that that made visits to patient #1. The day he/she visited patient (12/12/2024), the patient was up in a Brada Chair (a chair or wheelchair that provides comfort, support, and mobility) so he/she did not assess the patient’s skin. The ALF nurse said he/she had already assessed the skin and there was no wound. Then the hospice aide sent a picture that the wound was open, the case manager called the ALF nurse and gave the treatment orders, and the ALF nurse said he/she would have to get his/her own orders. He/she never takes another nurse’s word for an assessment. He/she does not look at the ALF medication or treatment administration records, he/she only asks the ALF staff if there have been any patient changes. The patient went to the hospital due to the patient’s daughter deciding to get aggressive treatment per triage (The ALF did not have orders for the Medi-honey and there was no evidence of daily dressing changes being completed as ordered). During an interview on 03/12/2025 at 8:55 AM, the director of clinical services stated the following:- Orders were usually received from the hospice medical director unless another physician was elected;- Any orders given to the facilities were placed in the red binders at the facility;- The physician orders should match, hospice should be educating staff if this was not happening, verbally update the staff and let the physician know (if orders do not match);- The ALF staff communicated with the hospice physician through the hospice nurse, who communicate with the hospice physician through IDG, teams, and phone calls;- He/she thought the education to the ALF was effective and that the wound care orders were provided;- They do not have access to the ALF’s documentation, medication and treatment administration record and have trouble when giving orders to a particular nurse at the ALF;- The wound measurements (missing the unit of measurement) were in cm and staff were to measure weekly;- The case manager educated the ALF on the new orders, and they did not let the hospice nurse know they had different orders and how would hospice know that;- The hospice can get orders from any physician and relay to the facility, and it was up to the facility if they have other orders or different orders;- They provided wound treatment for comfort and if the patient had not gone to the hospital they would have continued to treat the wound (Treatments were not being completed as ordered);- “The hospice orders were the ALF orders and when the wound declined the case manager was educating on the hospice orders”;- The facility was to notify the hospice of any changes in the patient’s condition; and- During the IDG meeting on 12/12/2024 they discussed the patient’s wound while showing the picture of the wound on a screen, but they did not document the specific discussion. During an interview on 03/12/2025 at 10:35 AM, the case manager stated that:- He/she was not aware the hospice and ALF did not have the same orders;- The ALF nurse was doing daily dressing changes (the ALF record failed to show daily dressing changes);- He/she always goes through the hospice medical director to get orders (the hospice medical director was not the patient’s attending physician);- Sometimes he/she would go to the ALF and the wound care was not done and he/she would educate the ALF nurse (the ALF record did not show daily wound care); and- He/she should have increased visits, but the facility was to provide all the care. During an interview on 03/12/2025, the hospice medical director stated that he/she was not aware the ALF had an attending physician. If a patient had an attending physician, he/she would only be the back-up in the event the attending physician was not available. If there were conflicting orders it should have been brought to the hospice’s attention so they could communicate with each other and resolve the problem immediately. He/she could not recall any issues discussed regarding conflicting orders. Any issue brought to the hospice’s attention will be addressed. During an interview on 03/12/2025 at 11:45 AM the ALF (assisted living facility) administrator stated that:- The ALF staff and hospice nurse were supposed to collaborate and call the family together;- If there was a new order, hospice can initiate the order with the ALF nurse and the ALF nurse always follows up with their physician (attending physician);- He/she knew the hospice provider collaborated with their physician (hospice medical director), and the (ALF) consulted with theirs (the attending physician);- If there were any discrepancies, they would let their physician know;- The hospice nurse did collaborate with the ALF nurse; and- What was in the hospice chart was different than the ALF chart and the date the order changed (for wound care on 12/12/2024) was not in the hospice nurse note that was left at the ALF and the hospice nurse did not notify the ALF nurse and that was “when the trouble started”. During an interview on 03/17/2025 at 12:33 PM, the ALF administrator stated that the hospice staff always want a copy of their medical records to put in their hospice records. They can look at medical information anytime they want to, and “how else are you supposed to coordinate care if you don’t share medical records/information or look at the chart”.During an interview on 03/17/2025 at 1:22 PM, the patient’s family member stated that hospice never informed him/her of the patient’s wound; Findings included: Review of provider’s policy titled, “Patient Plan of Care,” revised January 2014, showed in part:- Purpose - To provide continuity of care; and- The plan of care will include all services necessary for the palliation and management of the terminal illness and the related conditions, including interventions to manage pain and symptoms, and drug and treatment necessary to meet the needs of the patient. RECORD/PATIENT #8:Review of the clinical record showed the patient was admitted to hospice services on 11/18/2024 with a terminal diagnosis of brain cancer and a secondary diagnosis of pressure sores (skin injury caused by unrelieved pressure) on the buttocks and genitalia. The patient resided at a friend’s home and his/her friend served as the patient’s primary caregiver (PCG). Review of the nursing visit note patient assessment, dated 01/14/2025, showed the following genitourinary (GU) findings:- The patient had a 16 French, 10 milliliter (ml) bulb, indwelling urinary catheter (a sterile tube placed in the bladder to drain urine); - Urine output - good;- Urine color – amber;- Sediment /cloudy appearance;- Unusual odor- foul smelling; and- Note – removed leaking urinary catheter and replaced with a new urinary catheter. Obtained immediate output of 900 milliliters (ml) of amber urine. The skilled nurse (SN) note also showed the SN discussed concerns with the social worker (SW) that there was a potential need for long-term care facility placement due to the high level of care required by the patient. The plan was for the SN and SW to visit and assess the patient’s needs. Review of the nursing visit note patient assessment, dated 01/17/2025, showed the following GU assessment findings:- An indwelling urinary catheter in place, dependent to gravity, draining dark amber urine with 650 ml of output; and - The SN failed to document additional GU assessment findings.Review of the nursing visit note / psychosocial visit note, dated 01/21/2025, showed the following: -The purpose of the visit was to discuss a respite stay for the patient;- The patient rated their pain as a 10/10 (based on a zero (0) to 10 pain scale in which 0 indicated no pain and 10 indicated the worst possible pain); - The patient was hollering out during the visit and wanted to go to the hospital due to genital pain from the urinary catheter and the wound on his/her genitalia; and- The patient revocated hospice services and was transported to the hospital by emergency medical services (EMS) on 01/21/2025. Review of the patient’s hospital emergency department records, dated 01/21/2025, showed the following diagnoses: -Urinary tract infection; and- Leukocytosis (a condition characterized by an elevated white blood cell (WBC) count. Elevated WBCs are often a sign of infection). During an interview on 03/25/2025 at 12:30 PM, the registered nurse coordinator stated that the nurse should have informed the the patient’s physician of the 01/14/2024 genitourinary assessment findings and symptoms.”

“Based on current survey findings, administrator job description review, and interview, the hospice provider failed to ensure compliance was achieved with four Conditions of Participation: Patient rights (§418.52), Interdisciplinary group, care planning, and coordination of services (§418.56), Core services (§418.64), and Organization and administration of services (§418.100). These deficient practices have the potential to affect the administrative oversight for care for all the patients on service with the provider. Findings included:The current survey findings showed the hospice administrator failed to effectively manage the overall day-to-day operations of the provider resulting in noncompliance at an immediate jeopardy (IJ) level as follows: - §418.56 Interdisciplinary group, care planning, and coordination of services. An immediate jeopardy level for actual harm to one patient (Patient #1) and potential for future harm to other patients was identified during the survey; - The findings were confirmed as immediate jeopardy by the Centers for Medicare & Medicaid Services (CMS);- On 03/12/2025 at 4:54 PM, the administrator was informed verbally and in writing via the IJ Template, of the finding(s) identified at an immediate jeopardy level;- A formal written removal plan was submitted by the hospice provider prior to the survey exit;- This removal plan was reviewed by CMS, and it was determined on 03/13/2025, that a satisfactory removal plan had been initiated related to the immediate jeopardy findings; and- The condition level deficiency identified above remains as cited. During the complaint investigation and certification survey three additional condition-level deficiencies were identified at §418.56 Patient rights, §418.64 Core services, and §418.100 Organization and administration of services.Review of the document titled, “Job Description: Executive Director/Administrator,” dated January 2014, showed in part that the administrator assures compliance with the Department of Health rules and regulations and (will) be knowledgeable of all applicable federal, state and local laws, and administrative rules. During an interview on 03/25/2025 at 1:20 PM, the administrator stated that at the time the IJ was cited, they (the provider) had already identified the problem and initiated a process improvement project.”

“Based on record review and interview, the hospice provider failed to ensure the clinical record contained documentation of interdisciplinary team communication and physician notification in two of 14 records reviewed (Records/Patients #4 and #8). This deficient practice has the potential to affect all the patients served by the provider. Record/Patient #4: Review of the clinical record showed the patient was admitted to hospice services on 09/26/2024 with a terminal diagnosis of malignant neoplasm of the lower lobe, left bronchus, or lung (a cancer in the lung or airway of the lung). The patient resided in an assisted living facility (ALF). Review a skilled nurse (SN) note dated 02/25/2025, showed the following: - The patient was experiencing nausea, vomiting, congestion, and fever; - The patient was lying in bed, pale, ill looking, and according to ALF staff the patient had been in bed since Sunday (02/23/2025); - The patient was unable to tolerate intake or oral medications due to vomiting; - The patient had coarse congestion in the lungs (normal lung sounds are clear); - The patient was hot to the touch from fever and diaphoretic; and - Under the heading communication with other team members the note indicated that durable medical equipment (DME) was ordered for the patient. Review of an outlook message dated 02/25/2025, showed the medical director was notified by the SN that the patient had a change in condition that included: not out of bed since Sunday, febrile and diaphoretic, nausea and vomiting, and congestion and the SN failed to document in the clinical record that the physician was notified of the patients change in condition. During an interview on 03/27/2025 at 11:50 AM, the registered nurse coordinator stated that the physician notification should have been documented in the clinical record. Findings included: Review of the provider’s undated document titled, “Interdisciplinary Group (IDG) and Frequency Guidance to Staff,” showed staff are directed to inform appropriate staff of a missed visit.RECORD/PATIENT #8:Review of the clinical record showed the patient was admitted to hospice services on 11/18/2024 with a terminal diagnosis of brain cancer and a secondary diagnosis of pressure sores (skin injury caused by unrelieved pressure) on the buttocks and genitalia. The patient resided at a friend’s home and his/her friend served as the patient’s primary caregiver (PCG).Review of the hospice aide progress note, dated 01/07/2025 at 09:28 AM, showed Hospice Aide (HHA) #30 was unable to make the patient’s assigned visit and informed the RN using cellular phone text messaging.-Review of the Hospice Aide Progress Note dated 01/08/2025 at 02:48 PM, showed HHA #30 was unable to make the patient’s assigned visit and informed the RN using cellular phone text messaging. During an interview on 03/26/2025 at 10:25 AM, the RN Coordinator stated that the HHA #30 used texting to inform the RN of the missed visits however, the text messages are not part of the patient’s medical records. The RN Coordinator stated that the provider did not have a policy regarding documentation and a method of communication regarding missed visits between staff and physicians in the patient’s medical record.”

“Based on policy review, record review, and interview the hospice provider failed to ensure a discharge summary was sent to the attending physician in one of two discharged records reviewed (Record/Patient #10). This deficient practice has the potential to affect all the discharged patients served by the provider. Findings included:Review of the provider’s policy titled, “Discontinuance of Hospice Care,” dated 01/2014, showed in part:- The patient/legal representative may request at any time a transfer to the services of another hospice or home care agency;- Upon request of the patient/caregiver, a written summary will be provided to the accepting agency and shall include the services being provided and the specific medical, psychosocial, spiritual needs being provided and needs requiring follow-up; and- The policy failed to contain the requirement that a discharge summary should be sent to the attending physician upon discharge.RECORD/PATIENT #10:Review of the clinical record showed the patient was admitted to hospice services on 08/30/2024 with a terminal diagnosis of Alzheimer’s Disease (a disease marked by progressive loss of mental capacity) with late onset and the patient transferred to a different hospice provider on 02/26/2025, per the caregiver’s request.A discharge summary was completed by the skilled nurse on 02/26/2025 and a review of a check list of information, sent to the receiving hospice provider, showed the discharge summary was sent to the receiving hospice provider on 03/25/2025 (during the recertification survey), and not provided to the attending physician.During an interview on 03/27/2025 at 11:50 AM, the registered nurse coordinator stated that he/she would have expected the discharge summary to be sent to the attending physician and sent to the physician prior to 03/25/2025.”

“Based on policy review, clinical record review and interview the hospice provider failed to ensure a copy of the inpatient provider’s discharge summary was available to the hospice at the time of discharge in one of one respite records reviewed (Record/Patient #6). This deficient practice has the potential to affect the coordination of care for all of the provider’s patients. Findings included: Review of the document titled, “Continuity of Care Between Inpatient Setting and Home,” dated January 2014, showed in part, that one copy of the inpatient clinical record, including a discharge summary, will be sent to the hospice immediately following a discharge or as soon as it is reasonably available. RECORD/PATIENT #6: Review of the clinical record showed the patient was admitted to hospice services on 08/26/2024 with a terminal diagnosis of ALS (amyotrophic lateral sclerosis; Lou Gehrig’s disease; a nervous system disease that causes loss of muscle control). The patient resided in the private residence of their ex-spouse who provided total care for all of their needs. The patient required transfer with a Hoyer lift (a mechanical lift used for transferring patients) and received nutrition via a gastrostomy tube (a tube placed surgically through the abdominal wall into the stomach for the administration of food, fluids, and medication). Review of the clinical record showed the patient was admitted to respite care on 10/24/2024 and remained for five days. The patient was discharged from respite on 10/29/2024 and returned to his/her home environment at that time. The clinical record failed to contain a discharge summary from the respite provider. During an interview on 03/25/2025 at 3:53 PM, the registered nurse coordinator stated that there was no discharge summary in the patient’s clinical record. He/she stated that it was not the practice of the provider to get a discharge summary from the inpatient provider at the end of the patient’s respite stay, the staff members coordinated care with the facility staff members and documented their coordination in the clinical record.”

“Upon patient record review, 12 of 19 (Patient #1, #3, #4, #5, #6, #8, #10, #11, #12, #14, #17, #18) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: Medication profile dated 9/12/2023 included Polyethylene glycol 17 GMs 1 scoop oral for constipation. There was no evidence of a diluent. Medication profile dated 10/11/2023 and another dated 10/17/2023 Included Tramadol 50mg PO Q 4 hrs PRN pain, duplicated. Corrected on site. Patient #3: Medication profile dated 8/15/2023 included Lidocaine patch 1 topical daily, 12 hrs. on , 12 hrs. off. There was no evidence of a site to apply. Dated 8/15/2023 O2 100% 3L continuous inhalation for dyspnea. There was no evidence of a route. Corrected on site. Patient #4: Medication profile dated 9/20/2023 and 11/1/2023 include Tramadol 50mg one BID PRN pain- duplicate orders. Corrected on site. Patient #5: Medication profile dated 7/12/2023 and 8/2/2023 duplicated Miralax 17 GM oral PO QD PRN constipation, with no evidence of a diluent. Corrected on site. Patient #6: Medication profile dated 10/3/2023 included O2 100% gas for inhalation 2L continuous. There was no evidence of a route. Corrected on site. Patient #8: Medication profile dated 5/26/2023 included Polyethylene glycol 17 GMs 1 scoop oral for constipation. There was no evidence of a diluent. Corrected on site. Patient #10: Medication profile dated 9/5/2023 included Polyethylene glycol 17 GMs 1 scoop oral for constipation. There was no evidence of a diluent. Corrected on site. Patient #11: Medication profile dated 10/13/2023 included Tramadol 50 mg 1 PO BID PRN pain, and 10/13/2023 Morphine concentrate 100mg/5ml, give 0.25ml (5mg) PO or SL Q 4 hours PRN Pain, no evidence of parameters of how to dispense. Corrected on site. Patient #12: Current Medication profile is missing an entry for Miralax (from 8/2/20230), had been discontinued, order still active. Patient #14: Medication profile dated 10/6/2023 included Oxycodone 5 mg PO Q 4 hr. PRN pain. Dated 10/6/2023 Morphine concentrate 100mg/5ml, give 0.25 ml/5 mg PO/SL Q 4 hr. PRN pain. There was no evidence of parameters for pain medications. Patient #17: Medication profile dated 12/14/2023 included Oxycodone 5mg IR take one Q 4 HR PRN pain, dated 3/10/2023 included Oxycodone 10mg/0.5ml, give 10 mg Q 4 hrs. PRN pain, dated 11/17/2022 Morphine concentrate 100mg/5ml, give 0.25ml/5mg SL/PO Q 4hrs PRN pain. No evidence of parameters. Patient #18: Medication profile dated 3/21/2023 included Tramadol 50mg PO PRN pain Q 6 hr, and dated 3/21/2023 Morphine conc. 100mg/5ml, give 0.25ml/5mg PO PRN Q 4hr for pain. There was no evidence of parameters for dispensing.”

“Upon patient record review, 3 of 19 (Patient #1, #8, #17) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #1, #8, #17: There was no evidence of a bereavement assessment.”

“Upon patient record review, 1 of 19 (Patient #8) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient’s progress toward desired outcomes • Reassessment of the patient’s response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #8: Last RN comprehensive update made 10/18/2023 (20 days).”

“Upon patient record review, 1 of 19 (Patient #4) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #4: Documented wounds on coccyx, on visits made 9/28, 10/5, 10/12, 10/19 and 10/26/2023 photographs were take of wound, no evidence of documented wound care provided or wound measurements done, per DCPS to be done weekly, and template is in place to do so.”

“Upon patient record review, 2 of 19 (Patient #11, #13) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions Patient #11: SOC terminal diagnosis is Alzheimer’s, CVA, COPD, CKD lV, Malnutrition. Patient has documented dysphagia. There was no evidence of a problem/interventions/goals related to neuro or cardiac/pulmonary. Patient #13: SOC terminal diagnosis is ALS, HTN. There was no evidence of a problem/interventions/goals related to neuro. Corrected on site”

“Upon patient record review, 12 of 19 (Patient #1, #3, #4, #5, #6, #8, #10, #11, #12, #14, #17, #18) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: Order dated 9/12/2023 included Polyethylene glycol 17 GMs 1 scoop oral for constipation. There was no evidence of a diluent. Order dated 10/11/2023 and another dated 10/17/2023 Included Tramadol 50mg PO Q 4 hrs. PRN pain, duplicated orders. Corrected on site. Patient #3: Order dated 8/15/2023 included Lidocaine patch 1 topical daily, 12 hrs. on , 12 hrs. off. There was no evidence of a site to apply. Dated 8/15/2023 O2 100% 3L continuous inhalation for dyspnea. There was no evidence of a route. Corrected on site. Patient #4: Order dated 9/20/2023 and 11/1/2023 include Tramadol 50mg one BID PRN pain- duplicate orders. Corrected on site. Patient #5: Order dated 7/12/2023 and 8/2/2023 duplicated Miralax 17 GM oral PO QD PRN constipation, and no evidence of a diluent. Corrected on site. Patient #6: Order dated 10/3/2023 included O2 100% gas for inhalation 2L continuous. There was no evidence of a route. Corrected on site. Patient #8: Order dated 5/26/2023 included Polyethylene glycol 17 GMs 1 scoop oral for constipation. There was no evidence of a diluent. Corrected on site. Patient #10: Order dated 9/5/2023 included Polyethylene glycol 17 GMs 1 scoop oral for constipation. There was no evidence of a diluent. Corrected on site. Patient #11: Order dated 10/13/2023 included Polyethylene glycol 17 GM oral PO QD PRN constipation, no evidence of a diluent. Order dated 10/13/2023 included Tramadol 50 mg 1 PO BID PRN pain, and 10/13/2023 Morphine concentrate 100mg/5ml, give 0.25ml (5mg) PO or SL Q 4 hours PRN Pain, no evidence of parameters of how to dispense. Corrected on site. Patient #12: Order dated 8/2/2023 and included in IDG dated 11/2/2023 included Miralax 17GM oral PO PRN constipation, no evidence of frequency or diluent. Patient #14: Order dated 10/6/2023 included Oxycodone 5 mg PO Q 4 hr. PRN pain. Dated 10/6/2023 Morphine concentrate 100mg/5ml, give 0.25 ml/5 mg PO/SL Q 4 hr. PRN pain. There was no evidence of parameters for pain medications. Corrected on site. Patient #17: Order dated 12/14/2023 included Oxycodone 5mg IR take one Q 4 HR PRN pain, dated 3/10/2023 included Oxycodone 10mg/0.5ml, give 10 mg Q 4 hrs. PRN pain, dated 11/17/2022 Morphine concentrate 100mg/5ml, give 0.25ml/5mg SL/PO Q 4hrs PRN pain. No evidence of parameters for dispensing. Patient #18: Order dated 3/21/2023 included Tramadol 50mg PO PRN pain Q 6 hr, and dated 3/21/2023 Morphine conc. 100mg/5ml, give 0.25ml/5mg PO PRN Q 4hr for pain. There was no evidence of parameters for dispensing.”

“Upon client record review, 7 of 19 (Patient #1, #2, #3, #6, #8, #11, #17) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: IDG dated 10/19/2023 included SW visits X 0/none in 15 days. A SW visit was made on 10/26/2023. IDG dated 10/19/2023 included SN 2-4 visits in 15 days. Five visits were made, 10/20. 10/23, 10/26, 10/30 and 11/1/2023. Patient #2: IDG dated 9/14/2023 included SW visits X 1 in 15 days. No visits were made. Patient #3: O2 orders dated 8/15/2023 included O2 3 L/NC continuously. SN notes dated 10/23/2023 included O2 at 2L via NC. SN notes date 10/2/2023 included O2 2L PRN via N/C, neither following prescribed amount. Patient #6: IDG dated 10/5/2023 included SN 4-6 visits in 15 days. Three visits were made, 10/9, 10/12 and 10/16/2023. Patient #8: IDG dated 9/7/2023 included SC o/none visits. Visit made 9/19/2023. 10/19/2023 included SN 2-4 visits in 15 days. One visit was made 10/23/2023. Patient #11: IDG dated 10/13/2023 included SN 2-3 visits in 15 days. Four visits were made, 10/14, 10/16, 10/19 and 10/23/2023. Patient #17: IDG dated 2/9/2022 included SW visits 1 in 15 days. Two visits were done, 2/17 and 2/21/2023.”