Phoenix Home Care and Hospice

“Based on record review and interview, the hospice failed to ensure drugs and biologicals were routinely available on a 24-hour bases, 7 days a week for hospice patients in, but not limited to, three of six records reviewed (Records/Patients #1, #2, and #3). This deficient practice has the potential to affect all hospice patients requiring timely access to ordered medications and biologicals. Findings included:Review of the provider’s policy titled “Medication Management”, last reviewed 03/16/2026, showed in part, the hospice will ensure medications necessary for pain control and symptom management are available 24 hours a day, seven days per week. RECORD/PATIENT #1Review of the on-call documentation dated 05/16/2026 reflected ordered medications were not available and would be delivered the following day.Observation on 06/08/2026 at 3:42 PM, showed the patient’s hydrocodone (used to relieve moderate to severe pain) prescription bottle was empty and the patient’s albuterol inhaler (used to treat or prevent breathing difficulties) contained no remaining medication.During an interview on 06/10/2026 at 10:24 AM, the caregiver stated that the patient ran out of hydrocodone on 05/15/2026 and did not receive the medication until 05/17/2026. The caregiver further stated the patient’s hydrocodone prescription and albuterol inhaler were depleted for several days prior to replacement medications being obtained, which was consistent with the observation on 06/06/2026 showing both medications were empty.During an interview on 06/08/2026 at 2:42 PM, the registered nurse case manager (RNCM) A stated that medications may not be available until the next day if a pharmacy could not be accessed after hours. RECORD/PATIENT #2Review of the RN initial assessment dated 05/12/2026, showed comfort medications were not initially placed in the home due to concerns regarding substance abuse. Review of the on-call documentation dated 05/16/2026 documented, “We do not have access 24/7 to pharmacy and patient is on service for COPD (chronic obstructive pulmonary disease).” The patient reported difficulty breathing at bedtime and increased anxiety. The note further showed the on-call registered nurse would deliver comfort medications later that evening. RECORD/PATIENT #3 Review of the on-call nursing note dated 05/15/2026 at 12:11 AM, showed that the patient’s spouse reported the patient had been nauseated and vomiting throughout the day. The note documented the patient required suppository medication; however, the nurse informed the patient’s spouse that the hospice did not have a 24-hour pharmacy available and all pharmacies were closed. The note further documented that the medication would be obtained first thing in the morning and delivered as the first patient visit of the day.Review of an agency-wide staff education email dated 05/18/2026 showed staff were educated regarding obtaining medications the same day for symptomatic patients.During an interview on 06/08/2026 at 12:45 PM, the assistant director of nursing stated that they did not have access to a 24-hour pharmacy. During an interview on 06/08/2026, the administrator stated that the provider had a 24-hour pharmacy available.These statements were inconsistent regarding availability and use of the hospice’s 24-hour pharmacy services.”

“Based on policy review, record review, home visit observation, and interview, the hospice provider failed to ensure:- Each patient and the primary care giver(s) received education and training for the care and services identified in the plan of care (L544); - The plan of care was individualized for each patient (L545); - The plan of care contained measurable outcomes (L548); - The plan of care included all medical supplies and appliances necessary to meet the needs of the patient (L550); - The plan of care was revised and included information from the patient’s updated comprehensive assessment and noted the patient’s progress towards outcomes and goals (L553); and- That the interdisciplinary group maintained responsibility for directing, coordinating, and supervising the care and services provided (L554). The cumulative effect of these deficient practices has the potential to affect all the patients served by the provider”

“Based on policy review, clinical record review, and interview the hospice provider failed to complete the comprehensive assessment for three of five full records reviewed (Records/Patients #1, #4, and #5). This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 09/20/2024 with a primary diagnosis of pancreatic cancer (the pancreas is an organ in the abdomen that produces hormones that regulate digestion and blood sugar levels). The patient had secondary diagnoses of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), diabetes (a group of diseases that results in too much sugar in the blood), and portal vein thrombosis (the formation of a blood clot in the veins of the liver). The patient resided in their own home with their spouse. Review of the document titled, “;RN Initial Assessment (registered nurse),” dated 09/20/2024 showed:- The patient had: * Abdominal pain rated seven on a PAINAD score (Pain Assessment in Advanced Dementia) with 10 the highest rating possible; * Hand and foot pain rated at five on an unidentified pain scale; * Was alert, and oriented to person, place, and time; * Clear speech, and was fully responsive; and * An implanted infusion port. - The assessment documentation failed contain a complete assessment identifying: * The patients pain assessment including the amount, frequency, and quantity of pain medications used to manage pain; * A pain scoring system individualized for the patient; * Identification of the pain scoring system used to assess the patients hand and foot pain; and * An assessment of the infusion port access including but not limited to the location of the port. During an interview on 11/21/2024 at 10:44 AM, the administrator stated that they would expect the assessment to be complete and accurate. Findings included: Review of the agencys policy, “;Plan of Care Process,” last reviewed 09/01/2024, showed in part: - Information will be gathered from the initial assessment to provide care and services to treat a patients and patients familys immediate care and support needs; -The contents of the comprehensive assessment will identify patient physical needs related to the terminal illness that will be addressed to promote the Hospice patients well-being, comfort, and dignity throughout the dying process; and -The update of the comprehensive assessment will be accomplished by the Hospice interdisciplinary group (IDG)/interdisciplinary team (IDT), in collaboration with the individuals attending physician, if any, and will evaluate changes that have taken place since the initial assessment. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice service on 07/05/2024 with a primary diagnosis of hypertensive heart disease with chronic congestive heart failure, and chronic obstructive pulmonary disease (COPD). The patient resided with his/her spouse in the home. Review of the initial skilled nurse (SN) assessment dated 07/05/2024 showed in part, target pain goal as three and pain level of five (medium) warrants further attention. Review of the SN recertification assessment dated 09/10/2024 failed to show a primary pain assessment. Review of the POC dated 07/05/2024, 07/12/024, 09/20/2024, 10/04/2024, 10/18/2024, 11/01/2024, and 11/15/2024 failed to show the acceptable level of pain and pain medication regimen. RECORD/CLIENT #4: Review of the clinical record showed the patient was admitted to hospice service on 10/16/2024 with a primary diagnosis of Parkinsons disease without dyskinesia, without mention of fluctuations (a neurological disorder that causes unintended or uncontrollable movements or stiffness, but currently without involuntary muscular movements or fluctuations). The patient resided with his/her spouse in the home. Review of the initial skilled nurse (SN) assessment dated 10/16/2024 failed to show a primary pain assessment. Review of the POC dated 10/18/2024 failed to failed to show the acceptable level of pain and pain medication regimen. During an interview on 11/21/2024 at 9:50 AM, the RN/regional executive director (governing body appointee)-A stated that the SN assessment included a pain assessment and the patients acceptable level of pain was expected to be in the POC.”

“Based on policy review, record review, observation, and interview, the hospice provider failed to ensure staff maintained an accurate/updated medication profile in five of five full records reviewed (Records/Patients #1, #2, #3, #4, and #5). This deficient practice has the potential to affect all patients served by the provider. Findings included:Review of the providers policy titled, “;Medication List and Monitoring,” last reviewed 09/01/2024, showed in part:- The hospice will review, monitor, and maintain a current, accurate list of all prescription and over the counter (OTC) medications, herbal remedies and other alternative treatments that could affect drug therapy taken by the patient; and- The medication/drug profile will be updated as frequently as necessary to reflect changes in the medication regimen, keeping the profile accurate. RECORD/PATIENT #3: Review of the clinical record showed the patient elected hospice on 05/03/2024 with a terminal diagnosis of cancer of the left breast. The patient had additional diagnoses of a left mastectomy (surgical removal of the breast), cerebral infarction (a stroke caused by blood vessel blockage), encephalopathy (a group of conditions that cause brain dysfunction), and hypertensive chronic kidney disease (impaired kidney function caused by high blood pressure). The patient lived in a long-term care facility (LTCF). Review of the hospices medication profile and the LTCFs most recent medication orders showed the following discrepancies: - The providers medication profile showed an order for acetaminophen (a non-narcotic pain reliever) 325 milligrams (mg), take two tablets every six hours as needed for pain. The LTCF medication profile showed the dosage was 500 mg tablets, take two every eight hours as needed; - The providers medication profile showed an order for “;wound cleanser” (no further description given), cleanse wound every other day and as needed. The LTCFs medication profile showed the wound cleanser is to be used daily; and - The LTCFs medication profile showed hyoscyamine sulfate (used to decrease excess secretions), 0.125 mg sublingual (given under the tongue) give one tablet every four hours as needed. The providers medication profile showed this medication was discontinued on 05/13/2024. During an interview on 11/21/2024 at 10:00 AM, the administrator stated that he/she would expect the medication list to be accurate and match the LTCFs medication profile. The nurse is supposed to ask about medication changes at each visit and at least monthly, print off a medication list and compare it to the LTCFs list. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice care on 09/18/2024 with a terminal diagnosis of Osteomyelitis (a bone infection) of the lumbar spine, and secondary diagnosis which included chronic kidney disease ( a condition where the kidneys gradually lose the ability to filter waste products from the blood), and senile dementia (a progressive disease that destroys memory and other important mental functions). The patient resided at home with a PCG. Review of the provider’s medication profile report, printed on 09/19/2024, found the patient was taking Senna Plus (to treat / prevent constipation) 50 mg - 8.6 mg BID (twice each day). Observation and interview on 11/19/2024 at 9:10 AM, a medication reconciliation between the provider’s medication profile, printed 11/19/2024, and the medications in the patient’s home showed the following medication discrepancies: The medication profile showed Lorazepam (an anti-anxiety agent) 0.5mg every four hours as needed; - Per the PCG the patient no longer took Lorazepam;- The medication profile showed aspirin (an antiplatelet agent) 81mg chewable one tablet daily;- Per the PCG the patient no longer took aspirin: - The medication profile showed Hyoscyamine Sulfate (used to treat bowel, ulcer and stomach conditions) 0.125 mg tablet;- Per the PCG the patient no longer took Hyoscyamine Sulfate;- Per the PCG the patient was still taking Senna Plus; and- The current medication profile (printed 11/19/2024) failed to show an order for the Senna Plus. 0.125 mg tablet; - Per the PCG the patient no longer took Hyoscyamine Sulfate; - Per the PCG the patient was still taking Senna Plus; and - The current medication profile (printed 11/19/2024) failed to show an order for the Senna Plus. During an interview on 11/21/2024 at 9:55 AM, the administrator stated that the printed medication profile to be accurate and reflect the medications the patient currently takes in the home. The medication should be reconciled by the licensed nursing staff during each patient visit. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice service on 07/05/2024 with a primary diagnosis of hypertensive heart disease with chronic congestive heart failure, and chronic obstructive pulmonary disease (COPD). The patient resided with his/her spouse in the home. Observation and interview on 11/19/2024 starting at 9:00 AM, showed the following discrepancies between the medication profile report dated 10/03/2024 to 12/31/2024 and the medications in the home: - The agencys medication profile showed Macrobid (an antibiotic used to treat urinary tract infections(UTI)) started on 11/18/2024; - Per the primary care giver (PCG), the Macrobid was not in the home as it had not been delivered; - The agencys medication profile showed Klor-con (used to prevent or to treat low blood levels of potassium) 20 milliequivalents (MEQ) one tablet, one time per day; - Per the PCG, the patient received potassium 10 MEQ one tablet at bedtime; - The Potassium prescription bottle showed 10 MEQ two times a day with food; - The agencys medication profile showed Gabapentin (used to treat nerve pain) 100 milligrams (MG) three capsules, three times a day; - Per the PCG, the patient started “;running low” on the prescription three weeks prior, so he/she was giving the patient three capsules in the morning and three at night; - The agencys medication profile failed to show an order for aspirin; - Per the PCG, the patient received aspirin 81 MG one time a day; - The agencys medication profile showed Ibratropium-Albuteral (used to prevent and treat difficulty breathing) Inhalation four times a day; - Per the PCG, the patient received a “;breathing treatment” two times a day; - The agencys medication profile failed to show an order for Coricidin; and - Per the PCG, the patient received Coricidin (antihistamine for high blood pressure sufferers) one tablet. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice service on 10/16/2024 with a primary diagnosis of Parkinsons disease without dyskinesia, without mention of fluctuations (a neurological disorder that causes unintended or uncontrollable movements or stiffness, but currently without involuntary muscular movements or fluctuations). The patient resided with his/her spouse in the home. Observation and interview on 11/19/2024 starting at 2:15 PM, showed the following discrepancies between the POC (plan of care) medication list dated 11/15/2024, the medications in the home, and skilled nurse (SN) visits dated from 10/17/2024 to 11/18/2024: - The POC showed Carbidopa-Levodopa (used to treat Parkinsons disease) one tablet, three times a day; - Per the PCG, the patient received Carbidopa-Levodopa, two times a day in the morning and at night; - The POC showed Seroquel (an antipsychotic medication) 25 MG, one tablet at bedtime; - Per the PCG, the patient received Seroquel 50 MG, a half tablet at bedtime; - Per the PCG, the patient “;occasionally” received Norco (a combination medication that contains hydrocodone (an opioid) and acetaminophen (an analgesic)) one time a day; -The POC failed to show an order for Norco; - Per the PCG, the patient received half a tablet “;today” of Lorazepam 0.5 MG; - The POC failed to show Lorazepam 0.5 MG; - The SN visit dated 11/18/2024 showed Morphine (an opioid medicine prescribed for severe pain) was available to the patient; and - The POC dated 11/15/2024 failed to show an order for Morphine. During an interview on 11/21/2024 at 9:50 AM, the director of nursing stated that the medication lists were reconciled at every skilled nurse visit. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 09/20/2024 with a primary diagnosis of pancreatic cancer (the pancreas is an organ in the abdomen that produces hormones that regulate digestion and blood sugar levels). The patient had secondary diagnoses of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), diabetes (a group of diseases that results in too much sugar in the blood), and portal vein thrombosis (the formation of a blood clot in the veins of the liver). The patient resided in their own home with their spouse. Review of the document titled, “;RN Skilled Nursing Visit (registered nurse),” dated 10/08/2024 showed that: - The patients last bowel movement was three days ago; and- The patient was taking [unidentified] stool softeners, two tablets twice per day. Review of the document titled, “;RN skilled Nursing Visit,” dated 10/14/2024 showed that the patient was to take tamsulosin 0.8 mg. for two weeks (a medication used to treat an enlarged prostate). Review of the document titled, “;Plan of Care Order,” dated 10/18/2024 showed the document failed to contain orders for: - Stool softeners as identified in the visit dated 10/08/2024; and- Tamsulosin as identified in the visit dated 10/14/2024. During an interview on 11/21/2024 at 10:44 AM, the administrator stated that they would expect the medication record to contain all of the medications used by the patient.”

“Based on policy review, job description review, record review, and interview, the hospice provider failed to ensure that each patient and the primary caregiver(s) received education and training for the care and services identified in their plans of care in two of five full records reviewed (Records/Patients #1 and #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy, “;Plan of Care Process,” last reviewed 09/01/2024, showed in part, the interdisciplinary group (IDG)/interdisciplinary team (IDT) will do the following: - Ensure that each patient and primary caregiver receives education and training as appropriate to their responsibilities for the care and services identified in the interdisciplinary plan of care (POC); and - Assess and document the patients and or representatives level of understanding, involvement, and agreement with the POC. Review of the Registered Nurse (RN)/ Case Manager Job Description dated 2021, showed in part: - Provide education to patients/family members regarding the dying process and plan of care; - Offer guidance with healthcare decisions; - Conduct an initial as well as ongoing comprehensive assessments of the patients; and - Observe signs and symptoms and report to the physician reactions to treatments, including drugs, as well as changes in the patients physical or emotional condition. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice service on 07/05/2024 with a primary diagnosis of hypertensive heart disease with chronic congestive heart failure (CHF; a decrease in the ability of the heart to pump blood), and chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient resided with his/her spouse in the home. Review of the skilled nurse (SN) visit on 09/26/2024 showed in part, the patient complained of increase wetness discharge with vaginal (female reproductive part) redness and yeast-like discharge. The SN stated that the patient had redness under right side of pannus (a flap or pouch of skin and tissue that hangs off the abdomen). The SN failed to document any education provided to the patient and the primary care giver (PCG) regarding the redness and yeast-like discharge. Review of the SN visit on 09/30/2024 showed in part, the patient with increased redness to vulva (outer part of the female reproductive area) and inner thighs and redness under right side of pannus. The SN failed to document any education provided to the patient and the PCG regarding the redness. During an interview on 11/20/2024 at 4:15 PM, the RN/regional executive director (governing body appointee; GBA)-A stated that education should be provided to the patient and the PCG and documented in the POC. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice service on 10/16/2024 with a primary diagnosis of Parkinsons disease without dyskinesia, without mention of fluctuations (a neurological disorder that causes unintended or uncontrollable movements or stiffness, but currently without involuntary muscular movements or fluctuations). The patient resided with his/her spouse in the home. Review of the SN visit dated 11/04/2024, showed dietary modifications and education provided to the primary care giver. During an interview on 11/21/2024 at 9:50 AM, the GBA-A stated that it was expected that the dietary modifications and explanation of the education for the dietary modifications would be on the POC.”

“Based on policy review, clinical record review, and interview, the provider failed to ensure that each patient received an individualized written plan of care (POC) based off of problems identified in the initial, comprehensive, and updated comprehensive assessments, in five of five full records reviewed (Records/Patients #1, #2, #3, #4, and #5). This deficient practice has the potential to affect all patients served by the provider. . RECORD/PATIENT #3: Review of the clinical record showed the patient elected hospice on 05/03/2024 with a terminal diagnosis of cancer of the left breast. The patient had additional diagnoses of a left mastectomy (surgical removal of the breast), cerebral infarction (a stroke caused by blood vessel blockage), encephalopathy (a group of conditions that cause brain dysfunction), and hypertensive chronic kidney disease (impaired kidney function caused by high blood pressure). The patient lived in a long-term care facility (LTCF). Review of the initial assessment, dated 05/03/2024, showed the patients neurological status assessment was completed and the patient had clear speech, equal hand grips, and tremors. The assessment showed the patient did not have seizures. Review of the recertification assessment, dated 10/09/2024, showed the patients neurological status assessment was completed and the patient had garbled speech, weak hand grips, and tremors. The assessment showed the patient did not have seizures. Review of the POC, dated 10/30/2024, showed “;Alteration in Neurological” as an identified problem and the goals included “;Patient seizure activity will be minimized” and “;Patient/caregiver understands and properly administers medication for seizure control”. The patient did not have a seizure diagnosis, a seizure history, or take medications to control seizures. The provider failed to ensure the POC was individualized and patient specific. During an interview on 11/21/2024 at 10:00 AM, the administrator stated that the POC should be individualized and patient specific. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice service on 07/05/2024 with a primary diagnosis of hypertensive heart disease with chronic congestive heart failure, and chronic obstructive pulmonary disease (COPD). The patient resided with his/her spouse in the home. Review of the initial comprehensive assessment dated 07/05/2024, showed the patient had a foley catheter (a sterile tube placed in the bladder to drain urine). Review of the POC dated 07/05/2024 and 07/12/2024, failed to be individualized to show the patient had a foley catheter. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice service on 10/16/2024 with a primary diagnosis of Parkinsons disease without dyskinesia, without mention of fluctuations (a neurological disorder that causes unintended or uncontrollable movements or stiffness, but currently without involuntary muscular movements or fluctuations). The patient resided with his/her spouse in the home. Review of the initial comprehensive assessment dated 10/16/2024, showed in part: - The patient was able to communicate with family by “;mannerisms” when the patient needed to toilet. The patient was incontinent of bowel and bladder and wore incontinent products at all times; - The patient had a mechanical soft diet and was able to feed him/herself at times and required maximum assist; - The patients fall assessment score at nine (at risk for falling); and - The patient took an anticoagulants (used to prevent the blood from clotting) daily. Review of the POC dated 10/18/2024 failed to be individualized and include the patient was incontinent. Review of the POC dated 10/18/2024 and the interdisciplinary group (IDG) meeting notes dated 10/18/2024 failed to address the patients risk for falling and safety interventions or goals for the use of anticoagulants. Review of the POC dated 10/18/2024 showed the patient/caregiver were able to administer tube feeding and provide care for tube insertion site (the patient did not have a feeding tube). The POC failed to be individualized as it contained interventions not related to the patient. Review of the POC dated 11/01/2024 showed the patient had an incontinent goal as the patient/caregiver understood proper care of the indwelling catheter and the patient received proper care of the indwelling catheter (the patient did not have a indwelling catheter). The POC failed to be individualized as it contained interventions not related to the patient. During an interview on 11/19/2024 at 2:15 PM, the primary care giver (PCG) stated that the patient did not have a catheter and that he/she assisted the patient with eating a mechanical soft diet. During an interview on 11/20/2024 at 4:15 PM, the RN/regional executive director (governing body appointee)-A stated that the POC should be individualized for all patients and the use of anticoagulants should have been included in the POC. Findings included: Review of the provider’s policy titled,” Plan of Care Process dated revised 09/01/2024 showed in part: All hospice care and services furnished to patients and their families will follow an individualized Plan of Care (POC) established by the hospice Interdisciplinary Group /Team (IDG/IDT) in collaboration with the attending physician (if any), the patient representative, and the primary caregiver, if any of them so desire, and in accordance with the patient’s needs The hospice will develop an individualized POC for each patient. The POC must reflect patient and family goals and interventions based on the problems identified in the initial comprehensive assessment and updated comprehensive assessments. The POC will include all services necessary for the palliation and management of the terminal illness and related conditions. The hospice will review and revise patient care in accordance with changes in the patient’s condition, spiritual status, psychosocial status, residential environment, patient’s response to care, and changes that have occurred regarding diagnosis, treatment, medications precautions, and limitations. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice care on 09/18/2024 with a terminal diagnosis of Osteomyelitis (a bone infection) of the lumbar spine, and secondary diagnosis which included chronic kidney disease (a condition where the kidneys gradually lose the ability to filter waste products from the blood), and senile dementia (a progressive disease that destroys memory and other important mental functions. The patient resided at home with a PCG. Review of the skilled nurse (SN) home visit assessments showed the following: - On 9/18/2024, the patient napped on and off during the day, and sometimes woke up confused. - On 9/19/2024, the patient admitted to, “occasional” use of marijuana in the home. The patient reported not sleeping well at night. - On 9/20/2024, the patient stated he/she was frequently awaken at night by pain. - On 9/23/2024 and 10/03/2024, the patient had smoked in the home, and had multiple burn holes in clothing and bed linen. - On 10/04/2024, the patient had occasional constipation related to previous gastro- intestinal issues and pain medications. - On 10/08/2024, the patient had occasional constipation. - On 10/16/2024, the patient had occasional constipation. - On 10/19/2024, the patient caregiver had burnout and expressed moving the patient from home to a nursing care facility, following a non- injury fall and bedside commode. - On 10/22/2024, the patient had occasional constipation. - On 10/25/2024, the patient had occasional constipation, and was sleeping better at night, but continued to nap during the day. - On 11/01/2024, the patient had occasional constipation, and was observed smoking at a table in the home. - On 11/05/2024, the patient had occasional constipation. - On 11/08/2024, the patient had occasional constipation and - On 11/15/2024, the patient had occasion constipation. Review of the POC revised 11/15/2024 failed to be individualized regarding: - The patients altered sleep pattern; - The patients safety with smoking cigarettes in the home; - The patients “;occasional” use of marijuana in the home; - The patients fall without injury on 10/19/2024; - The PCG fatigue level; and - The patients bowel regimen for the reported “;occasional constipation”. During an interview on 11/21/2024 at 9:55 AM, the administrator and governing body member 1 stated that the POC should reflect an accurate listing of DME, patient safety issues with regard to falls, smoking, “occasional” marijuana use in the home, and contain a bowel movement regimen as the patient currently is prescribed pain medications and staff had documented, “occasional constipation” during the home visits, and address the need and request of volunteer/respite services. The POC should be individualized with specific with measurable goals. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 09/20/2024 with a primary diagnosis of pancreatic cancer (the pancreas is an organ in the abdomen that produces hormones that regulate digestion and blood sugar levels). The patient had secondary diagnoses of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), diabetes (a group of diseases that results in too much sugar in the blood), and portal vein thrombosis (the formation of a blood clot in the veins of the liver). The patient resided in their own home with their spouse. Review of the document titled, “;RN Initial Assessment,” dated 09/20/2024 showed that the patient had:- A history of opioid use and was hesitant to increase opioid use to reduce their pain; - Abdominal pain: * That was rated seven on a PAINAD (pain assessment in advanced dementia) scale; * With a goal of five on a PAINAD scale; - Hand and foot pain: * Rated five on a 0-10 high scale; and * Treated with gabapentin (a drug used to treat nerve pain);- Nausea, vomiting, and alternating bouts of constipation and diarrhea; - Diabetes (a group of diseases that results in too much sugar in the blood) and a high nutritional risk; and - An infusion port used for chemotherapy. Review of the document titled, “;Plan of Care Order,” dated 09/20/2024 showed the document failed to contain patient specific orders and interventions to address the patients: - Pain including: * The identification of the type of pain scale utilized by the patient; * Pharmacological and or non-pharmacological methods to control pain control; and * Any documentation of the patients hand and foot pain:- Gastrointestinal issues including: * Pharmacological and/or non-pharmacological methods to control nausea and vomiting; * A plan for alternating bouts of constipation and diarrhea; - Diabetes; and- Infusion port. During an interview of 11/21/2024 at 10:44 AM, the administrator stated that they:- Would expect interventions and orders to manage the patients diagnosis and symptoms to be included in the plan of care; and- They were unable to locate the interventions and orders on the patients plan of care.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure the plan of care (POC) contained individualized goals with measurable outcomes in five of five full records reviewed (Records/Patients #1, #2, #3, #4, and #5). This deficient practice has the potential to affect all patients served by the provider. Findings included:Review of the providers policy titled, “;Plan of Care Process,” last reviewed 09/01/2024, showed in part:- The POC must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments; and- The POC includes, but is not limited to, measurable outcomes anticipated from implementing and coordinating the POC. Review of the providers policy titled, “;Plan of Care Process – Addendum,” last reviewed 10/20/2023, showed “;the POC will include realistic and achievable goals and all physician orders”. RECORD/PATIENT #3: Review of the clinical record showed the patient elected hospice on 05/03/2024 with a terminal diagnosis of cancer of the left breast. The patient had additional diagnoses of a left mastectomy (surgical removal of the breast), cerebral infarction (a stroke caused by blood vessel blockage), encephalopathy (a group of conditions that cause brain dysfunction), and hypertensive chronic kidney disease (impaired kidney function caused by high blood pressure). The patient lived in a long-term care facility (LTCF). Review of the recertification assessment, dated 10/09/2024, showed in part the following: - The patient had a wound (identified as wound #1) on the left lateral ankle; - The onset date was 08/27/2024; - The wound was classified as an unstageable pressure injury (skin injury caused by unrelieved pressure); - Measurements were 2.1 centimeters (cm) long, 1.8 cm wide, and 0.1 cm deep; and - The wound had a scant amount of serosanguinous drainage (a thin, red discharge composed of serum and blood). Review of the POC, dated 10/30/2024, showed in part: - Wound #1 on the left lateral ankle was included as a current patient problem that required nursing intervention; - The POC goals included “;optimal skin integrity maintained”; and - The POC goals failed to include measurable outcomes. During an interview on 11/21/2024 at 10:00 AM, governing body appointee 1 stated that POC goals should be patient specific, attainable, realistic, and measurable. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice care on 09/18/2024 with a terminal diagnosis of Osteomyelitis (a bone infection) of the lumbar spine, and secondary diagnosis which included chronic kidney disease (a condition where the kidneys gradually lose the ability to filter waste products from the blood), and senile dementia (a progressive disease that destroys memory and other important mental functions. The patient resided at home with a PCG. Review of the POC, dated 11/15/2024, showed in part: - The problems of pain, psychosocial issues, and ineffective coping; and - The POC goals failed to include measurable outcomes for pain, psychosocial issues, and ineffective coping. During an interview on 11/21/2024 at 10:00 AM, governing body appointee 1 stated that POC goals should be patient specific, attainable, realistic, and measurable. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice service on 07/05/2024 with a primary diagnosis of hypertensive heart disease with chronic congestive heart failure, and chronic obstructive pulmonary disease (COPD). The patient resided with his/her spouse in the home. Review of the SN visit dated 10/29/2024, showed the following skin assessment: -Redness under pannus ((a flap or pouch of skin and tissue that hangs off the abdomen); and -Redness under both breast. Review of the SN visit dated 10/30/2024, showed the following skin assessment: -Bottom red; and -A hemorrhoid (a swollen vein in your lower rectum). Review of the POC, dated 11/01/2024, showed in part: - The POC goals included “;optimal skin integrity maintained”; and - The POC goals failed to include measurable outcomes. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 09/20/2024 with a primary diagnosis of pancreatic cancer (the pancreas is an organ in the abdomen that produces hormones that regulate digestion and blood sugar levels). The patient had secondary diagnoses of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), diabetes (a group of diseases that results in too much sugar in the blood), and portal vein thrombosis (the formation of a blood clot in the veins of the liver). The patient resided in their own home with their spouse. Review of the document titled, “;RN Initial Assessment,” dated 09/20/2024 showed that the patient had:- A history of opioid use and was hesitant to increase opioid use to reduce their pain; - Abdominal pain: * That was rated seven on a PAINAD (pain assessment in advanced dementia) scale; * With a goal of five on a PAINAD scale; - Hand and foot pain: * Rated five on a 0-10 high scale; and * Treated with gabapentin (a drug used to treat nerve pain);- A respiratory assessment including: * A productive cough of moderate amounts of tan/yellow sputum, * Shortness of breath with minimal exertion; and * The use of supplemental oxygen at 2.5 liters per minute per nasal cannula when sleeping; - Nausea, vomiting, and alternating bouts of constipation and diarrhea; - Diabetes and a high nutritional risk; and - An infusion port used for chemotherapy. Review of the document titled, “;Plan of Care Order,” dated 09/20/2024 showed the document failed to contain individualized goals with measurable outcomes to address the patients: - Pain including: * The types of different relaxation skills and diversional activities to meet the patients individual needs; * Identification of the patients acceptable level of pain relief and ability to engage in desired activities; * Identification of the patients desired activities; and * Any goals related to the patients hand and foot pain; - Respiratory status; - Gastrointestinal issues; - Diabetes; and- Infusion port. During an interview of 11/21/2024 at 10:44 AM, the administrator stated that they:- Would expect individualized goals and measurable outcomes to be included in the plan of care; and- They were unable to locate individualized goals and measurable outcomes on the patients plan of care.”

“Based on policy review, record review, observation, and interview, the provider failed to ensure the plan of care (POC) contained the medical equipment necessary to meet the needs of the patients in three of five full records reviewed (Records/Patients #2, #3, and #5). This deficient practice has the potential to affect all the providers patients receiving medical equipment. Findings included:Review of the providers policy titled, “;Plan of Care Process,” last reviewed 09/01/2024, showed in part the POC will include medical supplies, equipment, and appliances necessary to meet the needs of the patient. RECORD/PATIENT #3: Review of the clinical record showed the patient elected hospice on 05/03/2024 with a terminal diagnosis of cancer of the left breast. The patient had additional diagnoses of a left mastectomy (surgical removal of the breast), cerebral infarction (a stroke caused by blood vessel blockage), encephalopathy (a group of conditions that cause brain dysfunction), and hypertensive chronic kidney disease (impaired kidney function caused by high blood pressure). The patient lived in a long-term care facility (LTCF). Review of the POC, dated 10/30/2024, showed in part the patient: - Was at risk for falls; - Had a pressure injury (skin injury caused by unrelieved pressure) to the left lateral ankle; - Had the following DME: * A hospital bed; * A walker; and * A wheelchair Observation on 11/19/2024 at 9:00 AM, during the patients home visit, showed the patient also had a winged mattress (used to prevent patients from rolling out of bed), a bedside fall mat (used to prevent injury if the patient fell out of bed), a turning wedge (a special cushion used to help the patient maintain position in bed) and a pressure relieving wheelchair cushion. The provider failed to include this equipment in the patients POC. During an interview on 11/21/2024 at 10:00 AM, the administrator stated that he/she would expect all the patients DME to be on the POC. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice care on 09/18/2024 with a terminal diagnosis of Osteomyelitis (a bone infection) of the lumbar spine, and secondary diagnosis which included chronic kidney disease ( a condition where the kidneys gradually lose the ability to filter waste products from the blood), and senile dementia (a progressive disease that destroys memory and other important mental functions). The patient resided at home with a primary care giver (PCG). Review of the initial, comprehensive nursing assessment completed on 09/18/2024 failed to list Durable medical equipment (DME). During a home visit observation on 11/19/2024 at 9:00 AM, a walker, a wheelchair, a Rollator (mobility aid that helps people with walking difficulties), and bedside commode were present in the patients home (the POC failed to show this equipment). During an interview on 11/19/2024 at 9:30 AM, the PCG stated: - The patient had used both walkers, and the wheelchair to assist in ambulation since returning from a nursing facility; and - The bedside commode was recently added to the patient’s DME. During an interview on 11/21/2024 at 10:30 AM, the administrator and governing body appointee 1 stated that the DME should be listed on the patient’s POC. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 09/20/2024 with a primary diagnosis of pancreatic cancer (the pancreas is an organ in the abdomen that produces hormones that regulate digestion and blood sugar levels). The patient had secondary diagnoses of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), diabetes (a group of diseases that results in too much sugar in the blood), and portal vein thrombosis (the formation of a blood clot in the veins of the liver). The patient resided in their own home with their spouse. Review of the document titled, “;RN Initial Assessment,” dated 09/20/2024 showed that the patient had an oxygen concentrator and overbed table in the home. Review of the document titled, “;Plan of Care Order,” dated 09/20/2024 showed the document failed to oxygen equipment and an overbed table as durable medical equipment in the home. During an interview of 11/21/2024 at 10:44 AM, the administrator stated that they:- Would expect the DME and supplies utilized in the care of the patient to be included in the plan of care; and- They were unable to locate oxygen equipment and an overbed table on the patients plan of care.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure the plan of care (POC) was revised and updated based on the patient’s updated comprehensive assessment and noted the patient’s progress towards their outcomes and goals as specified in the POC in four of five full records reviewed (Records/Patients #1, #2, #4, and #5).This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “;Interdisciplinary Group (IDG) Roles and Responsibilities,” last reviewed 09/01/2024, showed in part:- The interdisciplinary group (IDG) responsibilities will include periodic reviews and updates of the plan of care for each patient receiving hospice care;- The IDG will update the comprehensive assessment no less frequently than every 15 days. A revised interdisciplinary POC (plan of care) will include information from the patients updated comprehensive assessment and will note the patients progress toward outcomes and goals specified in the POC; and- Evaluate the effectiveness of symptom management. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice care on 09/18/2024 with a terminal diagnosis of Osteomyelitis (a bone infection) of the lumbar spine, and secondary diagnosis which included chronic kidney disease (a condition where the kidneys gradually lose the ability to filter waste products from the blood), and senile dementia (a progressive disease that destroys memory and other important mental functions. The patient resided at home with a Primary Care Giver (PCG). Review of the skilled nurse (SN) home visit assessments showed the following: - On 09/18/2024, the patient napped on and off during the day, and sometimes woke up confused; - On 09/18/2024, the patient had severe chronic pain, unmanaged by opioids, the patient stated constant pain of seven or eight out of ten; - On 09/18/2024 the patient had a pain medication change from hydrocodone (narcotic pain reliever) 7.5 milligrams(mg) four times a day (QID) to morphine extended release (narcotic pain reliever) 15 mg two times a day and hydrocodone 7.5 mg as needed; - On 09/19/2024, the patient admitted to, “occasional” use of marijuana in the home. The patient reported not sleeping well at night; and - On 09/19/2024 the POC for pain management goal was listed as: Patient with safe discharge, patient/caregiver understand eligibility for hospice benefit, patient/caregiver receives appropriate referral for continuity of care and appropriate notice regarding potential discharge. Review of Interdisciplinary Group (IDG) meeting notes, dated 09/20/2024, showed that the document failed to contain revisions to the plans of care and updates to the patients goals and interventions to address: - Altered sleep patterns; - Marijuana use; and - Pain management. Review of the SN home visit assessments showed the following: - On 09/20/2024, the patient stated he/she was frequently awakened at night by pain; and - On 09/23/2024 and 10/03/2024, the patient had smoked in the home, and had multiple burn holes in clothing and bed linen. Review of the IDG meeting notes dated 10/04/2024, showed that the document failed to contain revisions to the plans of care and updates to the patients goals and interventions to address: - Altered sleep patterns; - Patient safety related to smoking; and - Pain management. Review of the SN home visit assessments showed the following: - On 10/04/2024, the patient had occasional constipation related to previous gastro-intestinal issues and pain medications; - On10/04/2024, the patient was assessed with a pain level of four out of ten; - On 10/04/2024, the POC for pain management goal was listed as: Patient with safe discharge, patient/caregiver understand eligibility for hospice benefit, patient/caregiver receives appropriate referral for continuity of care and appropriate notice regarding potential discharge; - On 10/08/2024, the patient was assessed with a pain level of six out of ten; - On 10/08/2024, the POC for pain management goal was listed as: Patient with safe discharge, patient/caregiver understand eligibility for hospice benefit, patient/caregiver receives appropriate referral for continuity of care and appropriate notice regarding potential discharge; - On 10/08/2024, the patient had occasional constipation; and - On 10/16/2024, the patient had occasional constipation. Review of the IDG meeting notes dated 10/18/2024, showed that the document failed to contain revisions to the plans of care and updates to the patients goals and interventions to address: - Altered sleep patterns; - Fall(s); - PCG fatigue; - Volunteer/Respite services; - A bowel regimen program; and - Pain management. Review of the SN home visit assessments showed the following: - On 10/19/2024, the patient caregiver had burnout and expressed moving the patient from home to a nursing care facility, following a non-injury fall into a bedside commode; - On 10/19/2024, the patient had no pain reported; - On 10/22/2024, the patient had occasional constipation; - On 10/25/2024, the patient had occasional constipation, and was sleeping better at night, but continued to nap during the day; and - On 11/01/2024, the patient had occasional constipation, and was observed smoking at a table in the home. Review of the IDG meeting notes dated 11/01/2024, showed that the document failed to contain revisions to the plans of care and updates to the patients goals and interventions to address: - Patient safety regarding smoking; - A bowel regimen program; and - Pain management. Review of the SN home visit assessments showed the following: - On 11/05/2024, the patient had occasional constipation; - On 11/05/2024, the POC for pain management goal was listed as: Patient with safe discharge, patient/caregiver understand eligibility for hospice benefit, patient/caregiver receives appropriate referral for continuity of care and appropriate notice regarding potential discharge; - On 11/08/2024, the patient had occasional constipation; - On 11/08/2024, the patient had pain four out of ten; and - On 11/08/2024, the patient had occasional constipation. Review of the IDG meeting notes dated 11/15/2024, showed that the document failed to contain revisions to the plans of care and updates to the patients goals and interventions to address: - A bowel regimen program; and - Pain management. During an interview on 11/21/2024 at 10:44 AM, the administrator and governing body appointee 1 stated that:- They would expect the IDG to update the plan of care including goals and interventions; and- The record failed to contain updates to the patients goals and interventions by the IDG. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice service on 07/05/2024 with a primary diagnosis of hypertensive heart disease with chronic congestive heart failure, and chronic obstructive pulmonary disease (COPD). The patient resided with his/her spouse in the home. Review of the initial skilled nurse (SN) assessment dated 07/05/2024 showed in part, target pain goal as three and pain level of five (medium) warrants further attention. Review of the SN recertification dated 09/10/2024 failed to show in part: -Primary pain assessment; -Current medication(s); -Target pain goal; -Response to the question “;What pain level warrants further attention?”; and -Number of breakthrough medications in the last 24 hours. Review of the POC dated 09/20/2024 and 10/04/2024 failed to show the acceptable level of pain and pain medication regimen. Review of the IDG meeting dated 10/04/2024 failed to show the acceptable level of pain and pain medication regimen. Review of the SN home visit assessments showed in part the following: -On 09/26/2024, the patient complained of increased “;wetness” discharge, vaginal (female reproductive part) redness with yeast like discharge, and redness under right side of the pannus (a flap or pouch of skin and tissue that hangs off the abdomen); -On 09/30/24, redness under right side of the pannus, yeast like rash and redness to inner thighs, and vaginal redness; -On 10/03/2024, redness under right side of the pannus and inner thighs; - On 10/07/2024, redness under right side of pannus; and - On 10/10/2024, redness under pannus and both breast. Review of the POC dated 10/04/2024 and 10/18/2024 failed to identify the pharmacological measures to reduce and/or prevent skin integrity issues. Review of the IDG meeting dated 10/04/2024 and 10/18/2024 failed to contain revisions to the plans of care and updates to the patients goals and interventions to address skin integrity issues. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice service on 10/16/2024 with a primary diagnosis of Parkinsons disease without dyskinesia, without mention of fluctuations (a neurological disorder that causes unintended or uncontrollable movements or stiffness, but currently without involuntary muscular movements or fluctuations). The patient resided with his/her spouse in the home. Review of the initial skilled nurse (SN) assessment dated 10/16/2024 showed in part, the client incontinent and wore incontinence products at “;all times” with no catheter. Review of the POC dated 10/18/2024 failed to identify incontinence goals and interventions. Review of the IDG meeting notes dated 10/18/2024 failed to contain revisions to the plans of care and updates to the patients goals and interventions to address incontinence. Review of the initial skilled nurse (SN) assessment dated 10/16/2024 failed to show a primary pain assessment. Review of the POC dated 10/18/2024 failed to failed to show the acceptable level of pain and pain medication regimen. Review of the IDG meeting notes dated 10/18/2024 failed to contain revisions to the plans of care and updates to the patients goals and interventions to address During an interview on 11/19/2024 at 2:15 PM, the primary caregiver stated that the patient had no catheter and used incontinent products. During an interview on 11/21/2024 at 9:50 AM, the RN/regional executive director (governing body appointee) GBA-A stated that problems identified on the SN assessment would be identified in the POC and discussed during the IDG meeting. GBA stated that the SN assessment included a pain assessment and the patients acceptable level of pain was expected to be in the POC. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 09/20/2024 with a primary diagnosis of pancreatic cancer (the pancreas is an organ in the abdomen that produces hormones that regulate digestion and blood sugar levels). The patient had secondary diagnoses of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), diabetes (a group of diseases that results in too much sugar in the blood), and portal vein thrombosis (the formation of a blood clot in the veins of the liver). The patient resided in their own home with their spouse. Review of the document titled, “;RN – Skilled Nursing Visit (registered nurse,” dated 09/21/2024 showed that:- The patient had an oxygen saturation of 85% during the visit that was accompanied by shortness of breath; and- The patients pain was rated at a seven on a 0-10 high scale, and the patients pain control goal was five on a 0-10 high scale. Review of the document titled, “;RN – Skilled Nursing Visit,” dated 09/23/2024 showed that:- The patient had a change in pharmacy; - The nurse requested a prescription for fentanyl (an opioid pain medication used to treat moderate to severe pain) 12.5 micrograms (mcg) patch; and- The patient was wearing pull-up style, disposable briefs for management of bowel incontinence. Review of the document titled, “;RN – Skilled Nursing Visit,” dated 10/01/2024 showed that the patient had started on antibiotic therapy for a urinary tract infection. Review of the document titled, “;IDG Meeting,” dated 10/04/2024 showed that the document failed to contain updates to the patients goals and interventions to address: - The patients low oxygen saturation accompanied by shortness of breath; - The addition of fentanyl patches to the patients medication regimen; - The use of pull-up style disposable briefs for the management of bowel incontinence; and- The initiation of antibiotic therapy for the treatment of a urinary tract infection. Review of the document titled, “;RN – Skilled Nursing Visit,” dated 10/08/2024 showed that:- The patient was experiencing: * Unstoppable hiccups; * Nausea and vomiting; * A productive cough and shortness of breath at rest; and * Pain rated at eight on a 0-10 high scale; and- Had begun taking: * An antibiotic to prevent urinary tract infections; and * Stool softeners twice a day. Review of the document titled, “;RN – Skilled Nursing Visit,” dated10/14/2024 showed that: - The patient was experiencing: * Severe nausea, vomiting, and diarrhea; * Shortness of breath and a productive cough; and * Increased pain; and- Had begun taking: * Fentanyl patch, 25 mcg.; and * Tamsulosin 0.8mg for two weeks. Review of the document titled, “;IDG Meeting,” dated 10/18/2024 showed that the document failed to contain updates to the patients goals and interventions to address:- The patient was experiencing: * Increased pain; * Diarrhea and was using stool softeners; * Shortness of breath and a productive cough; and * Intractable hiccups; and- Had had an increase in their pain medication to fentanyl patch 25 mcg. every three days. During an interview on 11/21/2024 at 10:44 AM, the administrator stated that:- They would expect the IDG to update the plan of care including goals and interventions; and- The record failed to contain updates to the patients goals and interventions by the IDG.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure the interdisciplinary group (IDG) directed, coordinated, and supervised the care and services provided in five of five records reviewed (Records/Patients #1, #2, #3, #4, and #5). This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #3: Review of the clinical record showed the patient elected hospice on 05/03/2024 with a terminal diagnosis of cancer of the left breast. The patient had additional diagnoses of a left mastectomy (surgical removal of the breast), cerebral infarction (a stroke caused by blood vessel blockage), encephalopathy (a group of conditions that cause brain dysfunction), and hypertensive chronic kidney disease (impaired kidney function caused by high blood pressure). The patient lived in a long-term care facility (LTCF). Review of the initial assessment, dated 05/03/2024, showed the patients neurological status assessment was completed and the patient had clear speech, equal hand grips, and tremors. The assessment showed the patient did not have seizures. Review of the recertification assessment, dated 10/09/2024, showed the patients neurological status assessment was completed and the patient had garbled speech, weak hand grips, and tremors. The assessment showed the patient did not have seizures. Review of the IDG meeting notes, dated 10/18/2024, showed patients seizure activity will be minimized and the patient/caregiver understands and properly administers medication for seizure control as patient goals. The patient does not have a diagnosis of seizures and does not take medication for seizures. The note contained a comment narrative entry that showed the following comment: “;Recertification plan of care(.) This plan of care has been presented to and discussed with the patient/caregiver/IDG.” The IDG notes failed to show coordination of care when they showed the patient had seizures when the patient did not have seizures. Review of the IDG meeting notes, dated 11/01/2024, showed patients seizure activity will be minimized and the patient/caregiver understands and properly administers medication for seizure control as patient goals. The patient does not have a diagnosis of seizures and does not take medication for seizures. The note contained a comment narrative entry that showed “;This plan of care has been presented to and discussed with the patient/caregiver/IDG.” The summary comments showed “;IDT (IDG) held with representatives of all disciplines, all patients were discussed comprehensively, and all frequencies were confirmed. Medications were reviewed by Medical Director and no changes/recommendations noted. Please see individual POCs for details”. The IDG notes failed to show coordination of care when they showed the patient had seizures when the patient did not have seizures. Review of the IDG meeting notes, dated 11/15/2024, showed patients seizure activity will be minimized and the patient/caregiver understands and properly administers medication for seizure control as patient goals. The patient does not have a diagnosis of seizures and does not take medication for seizures. The note contained a comment narrative entry that showed “;This plan of care has been presented to and discussed with the patient/caregiver/IDG.” The IDG notes failed to show coordination of care when they showed the patient had seizures when the patient did not have seizures. Review of the providers policy, “;Plan of Care Process,” last reviewed 09/01/2024, showed in part, the interdisciplinary group (IDG)/interdisciplinary team (IDT) will do the following: - Maintain responsibility for directing, coordinating, and supervising care and services provided; and - Update the comprehensive assessment no less frequently than every 15 days. A revised interdisciplinary POC will include information from the patients updated comprehensive assessment and will note the patients progress toward outcomes and goals specified in the POC. Review of the providers policy “;Indwelling Foley Catheter Insertion and Care,” dated 2008, showed in part the following: - Change the indwelling foley catheter every 30 days to prevent infection and adhesions; and - Physician notification, if applicable. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice service on 07/05/2024 with a primary diagnosis of hypertensive heart disease with chronic congestive heart failure, and chronic obstructive pulmonary disease (COPD). The patient resided with his/her spouse in the home. Review of the initial comprehensive assessment dated 07/05/2024, showed the patient had a foley catheter (a sterile tube placed in the bladder to drain urine). Review of the POC dated 07/05/2024 and 07/12/2024, failed to show the patient had a foley catheter. Review of the recertification assessment dated 09/10/2024 showed the patients foley catheter was last changed on 08/28/2024. Review of the SN (skilled nurse) visit dated 09/26/2024 showed the patients foley catheter was last changed on 08/27/2024. Review of the SN note dated 09/30/2024 showed the patients foley catheter was changed on 09/30/2024. Review of the IDG meeting dated 10/04/2024 showed the foley catheter was changed on 10/02/2024. The IDG failed to coordinate care and show a physicians order for the foley catheter change. Review of the SN note dated 11/12/2024 showed the patients foley catheter was changed on 11/12/2024. Review of the clinical record failed to show coordination of care and a physicians order to change the foley catheter on 08/27/2024, 08/28/2024, 09/30/2024, and 11/12/2024. During an interview on 11/20/2024 at 4:15 PM, the RN/regional executive director (governing body appointee)-A stated that physicians orders should have been obtained. RECORD/CLIENT #4: Review of the clinical record showed the patient was admitted to hospice service on 10/16/2024 with a primary diagnosis of Parkinsons disease without dyskinesia, without mention of fluctuations (a neurological disorder that causes unintended or uncontrollable movements or stiffness, but currently without involuntary muscular movements or fluctuations). The patient resided with his/her spouse in the home. Review of the initial comprehensive assessment dated 10/16/2024, showed in part, the following, the patient: - Could communicate with family by “;mannerisms” when he/she needed to toilet; - Incontinent (involuntary loss of bladder or bowel control) for bowel and bladder and wore incontinent products at all times; - Had a mechanical soft diet and was able to feed him/herself at times and required maximum assist; - Did not use a foley catheter; and - Did not use tube feeding. Review of the POC dated 10/18/2024, showed the patient/caregiver were able to administer tube feeding and provide care for tube insertion site. The POC failed to show coordination of care regarding: - The tube feeding when the patient did not have a tube feeding; and - The patient being incontinent. Review of the physician order dated 10/24/2024 showed the family requested the home health aide (HHA) visits to decrease to one time per week. Review of the IDG meeting dated 11/01/2024, showed the following: - Incontinence and a goal for the patient/caregiver to understand proper care of an indwelling catheter; - Dysphagia (difficulty swallowing) and a goal for the patient/caregiver able to administer tube feedings and provide care for tube insertion site; and - The IDG failed to coordinate care when they failed to recognize the patient did not have an indwelling catheter and tube feeding. Review of the HHA visits dated 11/01/2024, 11/07/2024, and 11/14/2024, showed HHA frequency at two times per week. The HHA care plan instructions showed a frequency of two times per week. Review of the POC dated 11/01/2024 and 11/15/2024 showed the HHA visit frequency as two times per week. The POC failed to show coordination of care when the visit frequency was not decreased as per family request. During an interview on 11/21/2024 at 10:30 AM, the RN/regional executive director (governing body appointee)-A stated that the IDG meetings were “;very specific” to each patient and the IDG members should have “;caught” the inconsistencies in the patients information. He/She stated that the hospice care plan should have been changed to reflect activities for one time per week. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice care on 09/18/2024 with a terminal diagnosis of Osteomyelitis (a bone infection) of the lumbar spine, and secondary diagnosis which included chronic kidney disease (a condition where the kidneys gradually lose the ability to filter waste products from the blood), and senile dementia (a progressive disease that destroys memory and other important mental functions). The patient resided at home with a primary caregiver (PCG). Review of the initial assessment dated 09/18/2024, showed the patients pain assessment of eight (8), with a pain goal of five (5) based on a one to ten (1-10) numeric scale to quantify the amount of pain. Patient pain uncontrolled, constant pain in the abdomen and lower back, occurred daily but not constant, and pain in the right knee. The current pain regimen hydrocodone (narcotic pain reliever) 7.5 milligrams (mg) four times a day (QID). Orders for Morphine (narcotic pain reliever)15 mg ER (extended release) with hydrocodone changed to as needed. Review of the POC date 09/19/2024 showed the pain management goal was listed as: Patient with safe discharge, patient/caregiver understand eligibility for hospice benefit, patient/caregiver receives appropriate referral for continuity of care and appropriate notice regarding potential discharge. Review of the SN assessment dated 10/04/2024, showed the patient had occasional constipation related to previous gastro-intestinal issues and pain medications. Review of the POC dated 10/04/2024, failed to show an updated POC for constipation prevention/bowel regimen. Review of the IDG meeting notes, dated 10/04/2024, failed to show coordination of care regarding: - The patients pain management; and - The patients constipation/bowel regimen. Review of the SN assessment dated 10/19/2024 showed caregiver burnout as a new concern. Review of social work (SW) assessment visit notes dated 10/21/2024 showed the patients PCG needed and requested at least two hours of volunteer services each week from the hospice provider. Review of the POC dated 11/01/2024, showed patients problem of pain, identified on 11/01/2024, progress unchanged toward goals of a safe discharge, understanding of hospice benefit, appropriate referral for continuity of care and appropriate notice regarding potential discharge. The POC failed to show an updated POC regarding caregiver burnout/volunteer services. Review of the IDG meeting notes dated 11/01/2024, failed to show coordination of care regarding caregiver burnout/volunteer services.”

“Based on policy review, record review, observation, and interview, the hospice provider failed to ensure the hospice aide performed hand hygiene before retrieving supplies from their bag in one of four home visit observations conducted (Record/Patient #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the providers policy titled, “;Bag Technique,” last reviewed 09/01/2024, showed in part, if additional supplies are needed after hands are contaminated during the visit, hands are decontaminated again before re-entering the bag. Review of the providers policy titled, “;Hand Hygiene,” last reviewed 12/15/2022, showed in part, an alcohol-based hand rub (ABHR) is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Staff may use an ABHR for routinely decontaminating hands in the following clinical situations: - Prior to initial entry into the supply bag; - After touching a patient or patients immediate environment; - After contact with blood, body fluids, or contaminated surfaces; and - After removing gloves. RECORD/PATIENT #3: Review of the clinical record showed the patient elected hospice on 05/03/2024 with a terminal diagnosis of cancer of the left breast. The patient had additional diagnoses of a left mastectomy (surgical removal of the breast), cerebral infarction (a stroke caused by blood vessel blockage), encephalopathy (a group of conditions that cause brain dysfunction), and hypertensive chronic kidney disease (impaired kidney function caused by high blood pressure). The patient lived in a long-term care facility (LTCF). Review of the document titled, “;Aide Care Plan,” dated 10/09/2024, showed the hospice aide was to provide a shower at every visit. Observation on 11/18/2024 at 9:30 AM, during the patients home visit, showed hospice aide-A was performing the patients shower, removed gloves, failed to wash or sanitize hands, reached into his/her supply bag and grabbed a bottle of body wash, donned gloves, and continued shower. Hospice aide–A completed the shower, dried and dressed the patient, removed gloves, failed to wash or sanitize his/her hands, reached into his/her bag, grabbed a gait belt, stated that he/she would prefer to use the gait belt laying by the patients wheelchair and returned the gait belt back to the bag. During an interview on 11/21/2024 at 10:00 AM, the administrator stated that he/she would expect the hospice aide to wash their hands or use ABHR after removing gloves and before going into their bag.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure the nurse obtained orders for treatments, procedures, and medications prior to usage, failed to ensure the nurse followed the plan of care, failed to ensure the nurse notified the physician as needed, and failed to ensure the nursing needs of the patient were met in four of five full records reviewed. This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #3: Review of the clinical record showed the patient elected hospice on 05/03/2024 with a terminal diagnosis of cancer of the left breast. The patient had additional diagnoses of a left mastectomy (surgical removal of the breast), cerebral infarction (a stroke caused by blood vessel blockage), encephalopathy (a group of conditions that cause brain dysfunction), and hypertensive chronic kidney disease (impaired kidney function caused by high blood pressure). The patient lived in a long-term care facility (LTCF). Review POC order update note dated 10/04/2024 showed the following orders: Cleanse wound to left lateral ankle with wound cleanser, pat dry. Apply Santyl (chemical agent used to remove dead tissue from a wound) to wound bed, back with dry gauze, secure with bordered dressing. Change daily and as needed if soiled or dislodged. Hospice nurse to change on visit days, long-term care facility (LTCF) staff to change all other days. The note also showed orders for skilled nursing (SN) visits two times a week. Review of the IDG meeting note, dated 10/04/2024, showed: - On 08/30/2024, dressing changed by LTCF staff prior to SN visit (the SN failed to follow orders for dressing changes and failed to assess wound); - On 09/20/2024, LTCF nurse changed dressing (the SN failed to follow orders for dressing changes and failed to assess wound); - On 09/24/2024, wound care completed by the LTCF staff prior to the SN arrival (the SN failed to follow orders for dressing changes and failed to assess wound); and - On 10/01/2024, dressing changed by LTCF staff prior to SN visit (the SN failed to follow orders for dressing changes and failed to assess wound). Review of the POC, dated 10/30/2024, showed the following orders: Cleanse wound to left lateral ankle with wound cleanser, pat dry. Apply Santyl (chemical agent used to remove dead tissue from a wound) to wound bed, back with dry gauze, secure with bordered dressing. Change daily and as needed if soiled or dislodged. Hospice nurse to change on visit days, facility staff to change all other days. The POC also showed orders for skilled nursing visits two times a week. Review of SN notes, with dates ranging from 10/11/2024 to 11/12/2024, showed in part: - On 10/11/2024, dressing changed by facility nurse prior to SN visit (the SN failed to follow orders for dressing changes and failed to assess wound); - On 10/15/2024, the SN documented wound to left lateral ankle dressing was CDI (clean, dry, and intact) (the SN failed to follow orders for dressing changes and failed to assess wound); and - On 11/12/2024, the SN documented treatment to left lateral ankle CDI, fcn (facility nurse) previously changed this AM (the SN failed to follow orders for dressing changes and failed to assess wound). During an interview on 11/21/2024 at 10:00 AM, the administrator stated that he/she would expect the nurse to do the dressing changes on the days they visit the LTCF as ordered in the POC. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice service on 07/05/2024 with a primary diagnosis of hypertensive heart disease with chronic congestive heart failure, and chronic obstructive pulmonary disease (COPD). The patient resided with his/her spouse in the home. Review of the skilled nursing (SN) visit dated 09/26/2024, showed the patient complained of increased wetness discharge, vaginal redness with yeast like discharge. Nystatin powder (used to treat fungal or yeast infections of the skin) was applied. The nurse applied the nystatin powder without a physicians order. Review of the providers “;Stand Down” notes (the providers email communication system) dated 09/26/2024, showed vaginal redness and nystatin cream was applied. Review of the providers “;Stand Down” notes dated 09/30/2024, showed the SN changed the foley catheter. The patient was “;pretty” red and irritated. The SN completed peri care and nystatin was applied. The SN failed to specify the application of nystatin cream or powder. The nurse changed the foley catheter and applied the nystatin without a physicians order. Review of the clinical record failed to show a physician order for nystatin cream and the foley catheter change. Review of the SN visit dated 11/18/2024, showed the SN “;reach out” to the physician regarding the patient complained of burning when “;peeing.” The physician ordered Macrobid (an antibiotic used to treat urinary tract infections(UTI)) for 10 days starting 11/18/2024 to 11/27/2024. Review of the pharmacy transmission history showed the Macrobid prescription was written on 11/18/24 at 11:34 AM. During an interview on 11/19/2024 at 10:00 AM, the primary care giver (PCG) stated that the Macrobid was not in the home as it had not been delivered. During an interview on 11/20/2024 at 4:30 PM, the skilled nurse stated the Macrobid was delivered on 11/20/2024. The SN failed to ensure the patient had his/her antibiotic as ordered for two days. RECORD/CLIENT #4: Review of the clinical record showed the patient was admitted to hospice service on 10/16/2024 with a primary diagnosis of Parkinsons disease without dyskinesia, without mention of fluctuations (a neurological disorder that causes unintended or uncontrollable movements or stiffness, but currently without involuntary muscular movements or fluctuations). The patient resided with his/her spouse in the home. Review of the physician order dated 10/26/2024, showed Cipro (an antibiotic used to treat urinary tract infections (UTI)) prescribed for three days starting 10/26/2024 and discontinued on 10/29/2024. Review of the SN visit dated 10/29/2024, showed the PCG reported the patient had a low-grade temperature and two nights with foul urine. Review of the pharmacy transmission history showed the Cipro prescription was written on 10/26/2024 at 12:10 PM. During an interview on 11/20/2024 at 4:30 PM the SN stated the Cipro was picked up on 10/29/2024. The SN failed to follow-up with the PCG regarding the receipt of the Cipro. During an interview on 11/19/2024 at 2:15 PM, the PCG stated that one time the patient had not received an antibiotic that was ordered for a UTI. The PCG called to “;remind” the provider about the prescription and the medication came the next day. During an interview on 11/21/2024 at 10:30 AM, the RN/regional executive director (governing body appointee)-A stated that the SN should have followed up with the family within 24 hours to ensure the antibiotic had been delivered. Findings included: Review of the undated document titled, “;Title of Position: Registered Nurse (RN)/Case Manager,” showed in part: - RN Duties: To plan, coordinate and provide hospice care in accordance with the patients plan of care; and- RN Responsibilities included: * Coordination of hospice care by working with other team members as well as with the patients/family members to ensure needs are met; * Evaluating the effectiveness of hospice services to the patient and family on an ongoing basis; * Consulting with the attending physician and hospice medical director concerning changes in patients condition requiring order changes and/or changes in the plan of care; * Taking responsibility for ensuring the patients plans of care are kept current; and * Providing education to patients/family members regarding the dying process, plan of care, and offers guidance with healthcare decisions. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 09/20/2024 with a primary diagnosis of pancreatic cancer (the pancreas is an organ in the abdomen that produces hormones that regulate digestion and blood sugar levels). The patient had secondary diagnoses of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), diabetes (a group of diseases that results in too much sugar in the blood), and portal vein thrombosis (the formation of a blood clot in the veins of the liver). The patient resided in their own home with their spouse. Review of the document titled, “;RN Skilled Nursing Visit,” dated 09/21/2024 showed in part that:- The patient had an oxygen saturation of 85% and shortness of breath. The visit documentation failed contain: * The interventions taken to bring the patients oxygen level into a normal range; * Physician notification of an oxygen saturation of 85% with shortness of breath; and * IDG notification of the patients symptoms; - The patient rated their pain at seven on a 0-10 high scale. The visit documentation failed to contain: * Physician notification of the patients pain greater than their stated goal of five on a 0-10 high scale; * Non-pharmacological methods to reduce the patients pain level; and * Patient education on pain management. Review of the document titled, “;RN Skilled Nursing Visit,” dated 09/23/2024 showed in part that:- The patient rated their pain at seven on a 0-10 high scale, the current pain management plan was ineffective, and the nurse was, “;working on changing up pain medications;” Review of the document titled, “;Physician Order,” dated 09/24/2024 showed the patient was to begin topical application of a fentanyl (an opioid pain medication used to treat moderate to severe pain) patch 12 micrograms (mcg) per hour every 3 days The clinical record failed to contain documentation that the patient was called between nursing visits to evaluate the effectiveness of the change in pain medication. Review of the document titled, “;RN Skilled Nursing Visit,” dated 10/01/2024 showed in part that:- The patients pain level was five on a 0-10 high scale; - The patient was struggling with nausea during the visit and was out of anti-nausea medication; and- The patient had not received the fentanyl patch ordered 09/24/2024. Review of the document titled, “;RN Skilled Nursing Visit,” dated 10/08/2024 showed in part that:- The patients pain level was eight on a 0-10 high scale, and the nurse was, “;adjusting medication in an attempt to lesson symptoms;”- The patient reported constant dizziness, and unstoppable hiccups;- The visit failed to contain documentation that: * The physician was notified of the patient experiencing constant dizziness, and unstoppable hiccups; and * An order to change the patients pain manage regimen was received. The clinical record failed to contain documentation that the patient was called between nursing visits to evaluate the effectiveness of the change in pain medication and onset of constant hiccups. Review of the document titled, “;RN Skilled Nursing Visit,” dated 10/14/2024 showed that: - The patient rated their pain a 10 on a 0-10 high scale; - The patient was experiencing severe nausea, vomiting, and diarrhea; - An order was received this date to increase the fentanyl patch to 25 mcg; - The visit failed to contain documentation that: * The physician was notified of the severe nausea, vomiting, and diarrhea; * The nurse provided interventions and instructions to alleviate the nausea, vomiting, and diarrhea. The clinical record failed to contain documentation that the patient was called between nursing visits to evaluate the effectiveness of the change in pain medication, nausea/vomiting, and diarrhea. Review of the document titled, “;MSW Visit (medical social worker),” dated 10/16/2024 showed that:- The patient continued to have nausea and vomiting; - The patient was dehydrated, and the hospice RN instructed the patient to go to the hospital for fluids; - The patient stated they did not want to go to the hospital for treatment and requested hydration at home; - The patient was, “;disappointed and hurting” that the provider would not provide palliative hydration at home. Review of the document titled, “;Skilled Nursing SOAP (subjective, objective, assessment, and plan) Visit,” dated 10/17/2024 showed that:- The patient had gone to the emergency room and received intravenous fluids to treat dehydration; - The patient was having less nausea and vomiting; - The patients pain was rated five on 0-10 high scale; and- The patient would be out of pain medication on 10/18/2024; and- The provider would make a follow up phone call, “;tomorrow” to assess the patients needs. Review of the document titled, “;Weekend call 10/18 to 10/20,” showed in part that:- The patient stated they were not nauseated; - They are out of morphine instant release completely- The patient was under the impression that the nurse was picking up their medications and the nurse was under the impression the spouse was picking up the medications; - The patient had an old bottle of morphine extended release that he would take instead of the morphine instant release; and- They would take the morphine ER every twelve hours until morphine IR available. They had 5 morphine ER pills on hand. During an interview on 11/20/2024 at 3:30 PM, RNA stated that:- They had spoken to the patient about them being out of morphine IR; - They offered to deliver morphine IR to the patient on 10/18/2024; - The patient adamantly refused to have the nurse come to the home because they had company; - The patient stated they had old morphine ER tablets, and they would take those tablets over the weekend; - They provided education to the patient that it was unsafe to use old medications; and- The physician and nursing supervisor was notified via email of the conversation with the patient. The clinical record failed to contain documentation that nursing spoke with the patient again until the next schedule nursing visit. Review of the document titled, “;RN Skilled Nursing Visit,” dated 10/22/2024 showed in part that:- The patient reported their pain was seven on a 0-10 high scale; - The patient would like the hospice provider to deliver medications to their home from this point forward; and- The record failed to contain documentation of physician notification of the patients pain rated higher than the goal of five on a 0-10 high scale. During an interview on 11/19/2024 at 1:45 PM the patient stated that:- The hospice nurse takes good care of them; - Their pain is generally rated seven on a 0-10 high scale and they have no desire to increase pain medications if the pain remain at that level; - The nurse kept offering to increase their pain medications and they keep refusing to take more; and- They were very satisfied with their pain and symptom management. During an interview on 11/21/2024 at 10:44 AM, the administrator stated that they would expect:- The clinicians to document all communication with physicians and patients in the clinical record;- The clinicians to follow up with the patients when changes are made to the plan of care to evaluate the effectiveness of those changes; and- They were unable to locate documentation of the communication and patient follow up in this clinical record.”

“Based on policy review, clinical record review, home visit observation, and interview the provider failed to provide hospice aide services as ordered by the interdisciplinary group (IDG) and included in the plan of care in two of three full records that had hospice aide (HA) services (Records/Patients #2 and #3). This deficient practice has the potential to affect all the patients that receive HA services. RECORD/PATIENT #3: Review of the clinical record showed the patient elected hospice on 05/03/2024 with a terminal diagnosis of cancer of the left breast. The patient had additional diagnoses of a left mastectomy (surgical removal of the breast), cerebral infarction (a stroke caused by blood vessel blockage), encephalopathy (a group of conditions that cause brain dysfunction), and hypertensive chronic kidney disease (impaired kidney function caused by high blood pressure). The patient lived in a long-term care facility (LTCF). Review of the POC order update note dated 10/04/2024 showed orders for hospice aide visits two times a week. Review of the document titled, “;Aide Care Plan,” dated 10/09/2024, showed the hospice aide was to perform the following tasks at every visit: - Assist to dress; - Comb hair; - Foot care; - Perineal care; - Shampoo hair; - Skin care; - Oral hygiene/denture care; - Check for pressure areas; - Nail care (file and trim only); - Complete shower; - Change linen; - Light housekeeping; - Make bed; and - Assist in transfers. The document also showed the hospice aide “;to notify RNCM (registered nurse case manager) of changes/concerns/missed visits or refusals of care at the time of visit”. Observation on 11/19/2024 at 9:30 AM, during the patients home visit, showed the hospice aide failed to perform oral hygiene/denture care, failed to change bed linens, and failed to make the bed. The hospice aide was also observed using a safety razor to shave the patients chin (this task was not on the aide care plan). Review of the aide care visit notes, with dates ranging from 10/04/2024 to 11/15/2024, showed in part: - On 10/04/2024, 10/09/2024, 10/11/2024, 10/15/2024, 10/18/2024, 10/22/2024, 10/25/2024, 10/29/2024, 11/06/2024, 11/09/2024, 11/12/2024, 11/15/2024, and 11/19/2024 the hospice aide documented that the task, “;Make Bed,” was not completed. The hospice aide failed to follow the care plan and failed to notify the RNCM that the task was not completed; - On 10/11/2024, 10/15/2024, 10/25/2024, 10/29/2024, 11/06/2024, 11/09/2024, 11/12/2024, 11/15/2024, and 11/19/2024, the hospice aide documented that the task, “;Change Linen,” was not completed. The hospice aide failed to follow the care plan and failed to notify the RNCM that the task was not completed; - On 10/29/2024, 11/06/2024, 11/12/2024, and 11/15/2024 the hospice aide documented that the task, “;Light Housekeeping,” was not completed. The hospice aide failed to follow the care plan and failed to notify the RNCM that the task was not completed; and - On 11/06/2024 and 11/19/2024 the hospice aide documented that the task, “;Oral Hygiene/Denture Care,” was not completed. The hospice aide failed to follow the care plan and failed to notify the RNCM that the task was not completed. During an interview on 11/21/2024 at 10:00 AM, governing body appointee 1 stated that he/she would expect the hospice aide to notify the RN if they were not completing a task and would expect the RN to document in the supervisory visit why the task was not completed. He/she would expect the hospice aide to ask the registered nurse to revise the aide care plan if extra care tasks were needed, such as shaving. He/she would expect them to only do tasks that are in the aide care plan. Findings included: Review of the provider’s policy titled, “Implementing Care and Treatment” dated 09/01/2024, showed in part: - The hospice Registered Nurse (RN) will oversee the assignment of a Hospice Aide (HA) to a particular patient initiating hospice aide services within a time frame to meet identified patient needs as identified in the plan of care (POC) and per the physician orders; - The HA will be provided with written instructions for the patient care prepared by the RN; - The HA will complete appropriate documentation; and - When the provision of care/treatment cannot be implemented as established on the POC the patient’s physician will be notified. The appropriate documentation will be completed and submitted by the assigned discipline. The Clinical Manager will be notified as appropriate. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice care on 09/18/2024 with a terminal diagnosis of Osteomyelitis (a bone infection) of the lumbar spine, and secondary diagnosis which included chronic kidney disease, (a condition where the kidneys gradually lose the ability to filter waste products from the blood), and senile dementia (a progressive disease that destroys memory and other important mental functions).The patient resided at home with a primary caregiver (PCG). Review of the physician order dated 09/18/2024, showed the family requested the HA visit one time per week. Review of the Aide Care Plan dated 09/24/2024, directed the HA to perform assistance to dress, complete bed bath, shampoo, and combo hair, perform perineal care, provide incontinence care, and foot care, provide skin and nail care, provide complete shower and shave, change linen, make bed, perform light housekeeping, and assist in ambulation. Review of the Aide Care Visit dated 9/24/2024, showed the HA documented the following personal care tasks as “;not completed”: - Assist to dress; - Complete bed bath; - Comb hair; - Foot care; - Pericare; - Shampoo hair; - Oral hygiene/denture care; - Nail care- clean only; - Shave; - Complete shower; - Change linen; - Make bed; - Assist in ambulation; - Catheter care; and - Incontinent care was not marked as being completed nor not completed, it was left blank. The aide failed to complete tasks as on the plan of care. Review of the Aide Care Visit dated 09/30/2024, showed the HA documented the following personal care tasks as “;not completed”: - Assist to dress; - Complete bed bath; - Comb hair; - Foot care; - Pericare; - Shampoo; - Nail care- clean only; - Shave; - Complete shower; - Change linen; - Make bed; - Assist in ambulation; and - Incontinence care. The aide failed to complete tasks as on the plan of care. Review of the Aide Care Visit dated 10/23/2024, showed the HA documented the following personal care tasks as “;not completed”: - Linen change; and - Make bed. The aide failed to complete tasks as on the plan of care. Review of the Aide Care Visit dated 10/29/2024, showed the HA documented the following personal care tasks as “;not completed”: - Linen change; and - Make bed. The aide failed to complete tasks as on the plan of care. Review of the Aide Care Visit dated 11/06/2024, showed the HA documented the following personal care tasks as “;not completed”: - Complete bed bath; - Comb hair; - Foot care; - Pericare; - Shampoo; - Nail care- clean only; - Shave; - Complete shower; - Change linen; - Make bed; - Assist in ambulation; and - Incontinence care. The aide failed to complete tasks as on the plan of care. Review of the Aide Care Visit dated 11/08/2024, showed the HA documented the following personal care tasks as “;not completed”: - Linen change; and - Make bed. The aide failed to complete tasks as on the plan of care. Review of the Aide Care Visit dated 11/13/2024, showed the HA documented the following personal care tasks as “;not completed”: - Shave; - Linen change; and - Make bed. The aide failed to complete tasks as on the plan of care. During an interview on 11/21/2024 at 10:30 AM, the administrator and governing body appointee A stated that the visit notes should reflect why personal care tasks were not completed as directed in the POC in the narrative section of the chart in addition to the “;not completed” comment.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure the hospice aide (HA) supervisory visits were accurate in three of three full records reviewed that had aide services (Records/Patients #2, #3, and #4). This deficient practice has the potential to affect all patients that receive aide services. RECORD/PATIENT #3: Review of the clinical record showed the patient elected hospice on 05/03/2024 with a terminal diagnosis of cancer of the left breast. The patient had additional diagnoses of a left mastectomy (surgical removal of the breast), cerebral infarction (a stroke caused by blood vessel blockage), encephalopathy (a group of conditions that cause brain dysfunction), and hypertensive chronic kidney disease (impaired kidney function caused by high blood pressure). The patient lived in a long-term care facility (LTCF). Review of the document titled, “;Aide Care Plan,” dated 10/09/2024, showed the hospice aide was to perform the following tasks at every visit: - Assist to dress; - Comb hair; - Foot care; - Perineal care; - Shampoo hair; - Skin care; - Oral hygiene/denture care; - Check for pressure areas; - Nail care (file and trim only); - Complete shower; - Change linen; - Light housekeeping; - Make bed; and - Assist in transfers. The document also showed the hospice aide “;to notify RNCM (registered nurse case manager) of changes/concerns/missed visits or refusals of care at the time of visit”. Review of the aide care visit notes, with dates ranging from 10/04/2024 to 11/15/2024, showed in part: - On 10/04/2024, 10/09/2024, 10/11/2024, 10/15/2024, 10/18/2024, 10/22/2024, 10/25/2024, 10/29/2024, 11/06/2024, 11/09/2024, 11/12/2024, 11/15/2024, and 11/19/2024 the hospice aide documented that the task, “;Make Bed,” was not completed. The hospice aide failed to follow the care plan and failed to notify the RNCM that the task was not completed; - On 10/11/2024, 10/15/2024, 10/25/2024, 10/29/2024, 11/06/2024, 11/09/2024, 11/12/2024, 11/15/2024, and 11/19/2024, the hospice aide documented that the task, “;Change Linen,” was not completed. The hospice aide failed to follow the care plan and failed to notify the RNCM that the task was not completed; - On 10/29/2024, 11/06/2024, 11/12/2024, and 11/15/2024 the hospice aide documented that the task, “;Light Housekeeping,” was not completed. The hospice aide failed to follow the care plan and failed to notify the RNCM that the task was not completed; and - On 11/06/2024 and 11/19/2024 the hospice aide documented that the task, “;Oral Hygiene/Denture Care,” was not completed. The hospice aide failed to follow the care plan and failed to notify the RNCM that the task was not completed. Review of the aide supervisory visits, with dates ranging from 10/09/2024 to 11/15/2024, showed the RN assessed the hospice aide performance as the following: - Follows client care plan as instructed was marked as “;Excellent”; - Documents appropriately was marked as “;Excellent”; - Timely notification to supervisor of clients needs or changes in condition was marked as “;Excellent”; - Adheres to organizational policies and procedures was marked as “;Excellent”; - The question, “;Is the aide maintaining open communication?” was marked as “;Yes”; and - The supervising RN failed to accurately assess the performance of the hospice aide in following the patients plan of care. During an interview on 11/21/2024 at 10:00 AM, governing body appointee 1 stated that he/she would expect the hospice aide to notify the RN if they were not completing a task and would expect the RN to document in the supervisory visit why the task was not completed. Findings included: Review of the provider’s policy titled, “Implementing care and treatment,” dated 09/01/2024, showed in part: - The hospice Registered Nurse (RN) will oversee the assignment of a Hospice Aide (HA) to a particular patient initiating hospice aide services within a time frame to meet identified patient needs as identified in the plan of care (POC)and per the physician orders. - The HA will be provided with written instructions for the patient care prepared by the RN. - The HA will complete appropriate documentation. - When the provision of care/treatment cannot be implemented as established on the POC the patient’s physician will be notified. The appropriate documentation will be completed and submitted by the assigned discipline. The Clinical Manager will be notified as appropriate. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice care on 09/18/2024 with a terminal diagnosis of Osteomyelitis (a bone infection) of the lumbar spine, and secondary diagnosis which included chronic kidney disease, (a condition where the kidneys gradually lose the ability to filter waste products from the blood), and senile dementia (a progressive disease that destroys memory and other important mental functions). The patient resided at home with a PCG. Review of the document titled, “;Aide Care Plan,” dated 09/24/2024, showed the hospice aide was to perform the following tasks at every visit: - Assist to dress; - Comb hair; - Foot care; - Pericare; - Shampoo hair; - Skin care; - Oral hygiene/denture care; - Nail care- clean only; - Shave; - Complete shower; - Change linen; - Light housekeeping; - Make bed; - Assist in ambulation; - Catheter care (which the patient did not have); and - Incontinent care. The document also showed the hospice aide “;to notify RNCM (registered nurse case manager) of changes/concerns/missed visits or refusals of care at the time of visit”. Review of the aide care visit notes, dated 09/24/2024 and 09/30/2024, showed the HA documented the following personal care tasks as “;not completed”: Assist to dress, comb hair, foot care, pericare, shampoo hair, oral hygiene/denture care, nail care- clean only, shave, complete shower, change linen, make bed, assist in ambulation, and catheter care. In the comments section it showed, updated the RNCM (it failed to show what the HA updated the RNCM about). The HA failed to follow the care plan. Review of the aide care visit notes dated 10/23/2024 and 10/29/2024 showed the HA documented the following personal care tasks as “;not completed”: linen change and make bed. In the comments section it showed, updated the RNCM (it failed to show what the HA updated the RNCM about). The HA failed to follow the care plan. Review of the aide supervisory visits, with dates ranging from 09/30/2024 to 11/05/2024, showed the RN assessed the hospice aide performance as the following: - Follows client care plan as instructed was marked as “;Excellent”; - Documents appropriately was marked as “;Excellent”; - Timely notification to supervisor of clients needs or changes in condition was marked as “;Excellent”; - Adheres to organizational policies and procedures was marked as “;Excellent”; - The question, “;Is the aide maintaining open communication?” was marked as “;Yes”; and - The supervising RN failed to accurately assess the performance of the HA in following the patients plan of care. During an interview on 11/21/2024 at 10:00 AM, governing body appointee 1 stated that he/she would expect the hospice aide to notify the RN if they were not completing a task and would expect the RN to document in the supervisory visit why the task was not completed. RECORD/CLIENT #4: Review of the clinical record showed the patient was admitted to hospice service on 10/16/2024 with a primary diagnosis of Parkinsons disease without dyskinesia, without mention of fluctuations (a neurological disorder that causes unintended or uncontrollable movements or stiffness, but currently without involuntary muscular movements or fluctuations). The patient resided with his/her spouse in the home. Review of the physician order dated 10/24/2024, showed the family requested the HA visits decreased to one time per week. Review of the aide care visit notes dated 11/01/2024, 11/07/2024, and 11/14/2024, showed the HA frequency at two times per week. The “;Aide Care Plan” instructions showed a frequency of two times per week. Review of the aide supervisory visits with dates ranging from 10/29/2024 to 11/11/2024, showed the RN assessed the hospice aide performance as the following: - The question, “; Is the aide plan of care updated?” was marked as “;Yes”; - The question, “;Is the aide maintaining open communication?” was marked as “;Yes”; and - The supervising RN failed to accurately assess the performance of the HA in following the patients plan of care. During an interview on 11/19/2024 at 2:15 PM, the PCG stated that the aide visits were one time per week. During an interview on 11/21/2024 at 10:30 AM, the RN/regional executive director stated that the POC should be updated to show HA visit frequency as one time per week.”

“Based on policy review, volunteer tracking information review, record review, and interview, the hospice provider failed to ensure volunteer hours equaled five percent (%) of the total patient care hours of all paid hospice employees and contract staff and failed to ensure volunteers were used in the day-to-day administrative and/or direct patient care services to meet the needs of the patient and/or caregiver in two of five full records reviewed (Records/Patients #2 and #4). This deficient practice has the potential to affect all patients receiving hospice services. Findings Included: Record review of the provider’s volunteer information requirement showed the volunteer administrative and direct patient care hours were documented at 2.12 percent of the 5.0 percent minimum of total patient care hours of paid and contract staff as required by state and federal regulations. Review of the provider’s policy titled,” Volunteers” dated 9/01/2024 showed in part: - “Patient Care Volunteers” means individuals who can help patients and families with activities such as household chores, shopping, and companionship; - The hospice will provide volunteer services on a day -to-day administrative and /or direct patient care roles; - Volunteers will provide day to day administrative and /or direct patient care roles in the amount that, at a minimum equals five percent of the total patient care hours of all paid hospice employees and contract staff; - The Interdisciplinary Group/ Team (IDG/IDT) will assess the need for a volunteer for a patient ,family and/or caregiver; and -The scope and frequency of volunteer services will be detailed on the plan of care and be necessary to meet the patient and family needs. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice care on 09/18/2024 with a terminal diagnosis of Osteomyelitis (a bone infection) of the lumbar spine, and secondary diagnosis which included chronic kidney disease, (a condition where the kidneys gradually lose the ability to filter waste products from the blood), and senile dementia (a progressive disease that destroys memory and other important mental functions). The patient resided at home with a primary caregiver (PCG). Review of the volunteer assessment dated 09/19/2024, showed staff conducted an assessment via the telephone per the PCGs request. The caregiver declined the need for volunteers at that time and knew they could request at any time. Would continue to communicate with the IDG and caregiver for needs. Review of the skilled nursing (SN) assessment dated 10/19/2024, showed a licensed nurse documented the medical diagnosis/purpose of the visit was caregiver burnout. The staff also documented the caregiver reported the patient had fallen twice during the night and knocked over the bedside commode, which soiled the patient. The caregiver also reported to the staff the patient was aggressive toward the caregiver by grabbing the caregiver’s arm and told the caregiver not to touch him/her during a provision of care. The caregiver being unable to keep the patient at home. A referral to social work for emergency placement for the patient was made during the visit as an intervention plan. Review of a staff electronic mail message dated 10/21/2024, showed a message regarding the visit by the licensed nurse requesting a social worker visit 10/21/2024. The caregiver unable to keep the patient at home and would like to start possible placement to a nursing facility. Review of the social worker (SW) assessment dated 10/21/2024, showed staff documented a social worker met with the patient and caregiver. The patient/caregiver requested the need for at least two hours of volunteer services from the provider. Respite care discussed but declined. Would follow-up with community resources that afternoon. Review of the SW assessment dated 10/22/2024, showed staff documented a social worker met with the patient and caregiver for an update and gave update on the patient’s and caregiver’s ability to find more support. The caregiver had a call into Medicaid to determine if the patient could get more help/support hours. Review of the SW assessment dated 11/12/2024, showed staff documented a social worker met with the patient and caregiver to update and receive an update on the patient’s and caregiver’s ability to find more support. The SW addressed the concerns and questions with the lack of volunteer assistances, so now the patient and PCG were finding their own provider. During a home visit interview on 11/19/2024 at 9:30 AM, the patients PCG stated that he/she had called the provider’s twice, and left messages, and had not heard from the volunteer coordinator (VC) since placing the calls. The PCG stated the purpose of the call was to try and get more volunteer hours for the patient as he/she was suffering illness him/herself and just needing some time for him/herself. During an interview on 11/19/2024 at 2:35 PM, the VC stated the following: -The provider currently had eight volunteers; -The VC assessed each patient for volunteer service needs, if initially declined, volunteer service were continually offered if a need was observed by other staff during visits, or by the patient/family request; -The VC attended the IDT meetings which were bi-weekly on Fridays; -The VC was unaware of any patient on service who needed or had requested volunteer services; -The VC provided the initial volunteer assessment on the patient on 09/19/2024, he/she had not conducted any additional assessments or visits on the patient; and -The social worker (SW) had not shared the patients request in needing or wanting volunteer service. During an interview on 11/20/2024 at 9:30 AM, SW-2 stated the following: -Social work assessments were completed as part of the admission to hospice service; -Social worker visits were performed usually one to two times each month and more often as needed; -SW attended the IDT meetings bi-weekly on Fridays; -During IDT meetings the SW was responsible to share any patient concerns, voiced or documented. Other disciplines attending the IDT meetings also share concerns to address patient needs; -If a patient concern was identified by the SW or any other discipline, the concern was identified, interventions were put in place, with goals which were documented on an updated on a patient’s plan of care (POC); -SW-2 was assigned to patient #2. -SW-2 agreed that patient #2’s PCG seemed to need more assistance in the home; and -SW-2 stated that he/she had sent an electronic mail message to the VC regarding the request for more volunteer hours. Review of the clinical record failed to show volunteer notes after the 09/19/2024 initial volunteer assessment. The hospice provider failed to meet the volunteer needs of the patient and the PCG. During an interview on 11/20/2024 at 2:15 PM, Governing Body Appointee A agreed a volunteer should be going to see patient #2. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice service on 10/16/2024 with a primary diagnosis of Parkinsons disease without dyskinesia, without mention of fluctuations (a neurological disorder that causes unintended or uncontrollable movements or stiffness, but currently without involuntary muscular movements or fluctuations). The patient resided with his/her spouse in the home. Review of the volunteer assessment of the initial comprehensive assessment dated 10/16/2024, showed the patients spouse accepted volunteer services on “;as needed” basis for caregiver relief. The VC noted he/she would continue to communicate with the patient and the interdisciplinary team for needs. Review of the Plan of Care (POC) dated 10/18/2024 showed an intervention for Caregiver Relief as volunteer to provide support, socialization, and/or respite for caregiver. Review of the clinical record failed to show volunteer notes after 10/18/2024. During an interview on 11/19/2024 at 2:15 PM, the PCG stated that he/she liked to “;go out” once a week to get his/her nails done so he/she could have a “;break.” Sometimes he/she needed to “;go out” and he/she picked up medications. Findings Included: Review of the provider’s policy titled,” Volunteers,” dated 09/01/2024, showed in part: - “Patient Care Volunteers” means individuals who can help patients and families with activities such as household chores, shopping, and companionship; - The hospice will provide volunteer services on a day -to-day administrative and/or direct patient care roles; - Volunteers will provide day to day administrative and /or direct patient care roles in the amount that, at a minimum equals five percent of the total patient care hours of all paid hospice employees and contract staff;- The Interdisciplinary Group/ Team (IDG/IDT) will assess the need for a volunteer for a patient, family and/or primary care giver (PCG); and-The scope and frequency of volunteer services will be detailed on the plan of care (POC) and be necessary to meet the patient and family needs. During the survey entrance on 11/18/2024 at 11:10 AM volunteer program percentage of volunteer hours was requested. Review of the provider’s volunteer percentage information showed the volunteer administrative and direct patient care hours were documented at 2.12 percent (%) of the 5.0 % minimum of the total patient care hours of all paid and contract staff. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice care on 09/18/2024 with a terminal diagnosis of osteomyelitis (a bone infection) of the lumbar spine, and secondary diagnosis which included chronic kidney disease, (a condition where the kidneys gradually lose the ability to filter waste products from the blood), and senile dementia (a progressive disease that destroys memory and other important mental functions). The patient resided at home with a PCG. Review of the volunteer assessment dated 09/19/2024, showed staff conducted an assessment via the telephone per the PCGs request. The PCG declined the need for volunteers at that time and knew they could request at any time. Would continue to communicate with the IDG and PCG for needs. Review of the skilled nursing (SN) assessment dated 10/19/2024, showed a licensed nurse documented the medical diagnosis/purpose of the visit was PCG burnout. The staff also documented the PCG reported the patient had fallen twice during the night and knocked over the bedside commode, which soiled the patient. The PCG also reported to the staff the patient was aggressive toward the PCG by grabbing the PCG’s arm and told the PCG not to touch him/her during a provision of care. The PCG being unable to keep the patient at home. A referral to social work for emergency placement for the patient was made during the visit as an intervention plan. Review of a staff electronic mail message dated 10/21/2024, showed a message regarding the visit by the licensed nurse requesting a social worker visit 10/21/2024. The PCG unable to keep the patient at home and would like to start possible placement to a nursing facility. Review of the social worker (SW) assessment dated 10/21/2024, showed staff documented a social worker met with the patient and PCG. The patient/PCG requested the need for at least two hours of volunteer services from the provider. Respite care discussed but declined. Would follow-up with community resources that afternoon. Review of the SW assessment dated 10/22/2024, showed staff documented a social worker met with the patient and PCG for an update and gave update on the patient’s and PCG’s ability to find more support. The PCG had a call into Medicaid to determine if the patient could get more help/support hours. Review of the SW assessment dated 11/12/2024, showed staff documented a social worker met with the patient and PCG to update and receive an update on the patient’s and PCG’s ability to find more support. The SW addressed the concerns and questions with the lack of volunteer assistances, so now the patient and PCG were finding their own provider. Observation on 11/19/2024 starting at 9:00 AM, showed the patient’s PCG looking fatigued, he/she had dark circles under his/her eyes and complained of being tired. During a home visit interview on 11/19/2024 at 9:30 AM, the patients PCG stated that he/she had called the provider’s twice, and left messages, and had not heard from the volunteer coordinator (VC) since placing the calls. The PCG stated the purpose of the call was to try and get more volunteer hours for the patient as he/she was suffering illness him/herself and just needing some time for him/herself. During an interview on 11/19/2024 at 2:35 PM, the VC stated the following:-The provider currently had eight volunteers;-The VC assessed each patient for volunteer service needs, if initially declined, volunteer services were continually offered if a need was observed by other staff during visits, or by the patient/family request;-The VC attended the IDT meetings which were bi-weekly on Fridays;-The VC was unaware of any patient on service who needed or had requested volunteer services;-The VC provided the initial volunteer assessment on the patient on 09/19/2024, he/she had not conducted any additional assessments or visits on the patient; and-The SW had not shared the patients request in needing or wanting volunteer service with him/her. During an interview on 11/20/2024 at 9:30 AM, SW-2 stated the following:-Social work assessments were completed as part of the admission to hospice service;-Social worker visits were performed usually one to two times each month and more often as needed;-SW attended the IDT meetings bi-weekly on Fridays;-During IDT meetings the SW was responsible to share any patient concerns, voiced or documented. Other disciplines attending the IDT meetings also share concerns to address patient needs;-If a patient concern was identified by the SW or any other discipline, the concern was identified, interventions were put in place, with goals which were documented on an updated on a patient’s POC;-SW-2 was assigned to patient #2.-SW-2 agreed that patient #2’s PCG seemed to need more assistance in the home; and-SW-2 stated that he/she had sent an electronic mail message to the VC regarding the request for more volunteer hours. Review of the clinical record failed to show volunteer notes after the 09/19/2024 initial volunteer assessment. The hospice provider failed to meet the volunteer needs of the patient and the PCG. During an interview on 11/20/2024 at 2:15 PM, RN (registered nurse)/regional executive director (governing body appointee; GBA)-A agreed a volunteer should be going to see patient #2. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice service on 10/16/2024 with a primary diagnosis of Parkinsons disease without dyskinesia, without mention of fluctuations (a neurological disorder that causes unintended or uncontrollable movements or stiffness, but currently without involuntary muscular movements or fluctuations). The patient resided with his/her spouse in the home. Review of the volunteer assessment of the initial comprehensive assessment dated 10/16/2024, showed the patients spouse accepted volunteer services on “;as needed” basis for PCG relief. The VC noted he/she would continue to communicate with the patient and the interdisciplinary team for needs. Review of the POC dated 10/18/2024 showed an intervention for PCG relief as volunteer to provide support, socialization, and/or respite for PCG. Review of the clinical record failed to show volunteer notes after 10/18/2024. During an interview on 11/19/2024 at 2:15 PM, the PCG stated that he/she liked to “;go out” once a week to get his/her nails done so he/she could have a “;break.” Sometimes he/she needed to “;go out” and he/she picked up medications.”

“Based on policy review, current survey findings, and interview, the hospice provider failed to provide hospice care that optimized comfort and dignity and was consistent with patient and family needs and goals. This deficient practice has the potential to affect all patients on service with the provider. Findings included:Review of the document titled, “;Governing Body,” last revised 09/01/2024 showed in part:- The governing bodys responsibilities will include but are not limited to ensuring provision of all hospice care and services that: * Optimizes comfort and dignity; and * Is consistent with patient and family needs and goals, with patients needs and goals a priority. The current survey findings showed the organization failed to effectively ensure the provision of hospice care and services that optimized patient comfort and dignity, and was consistent with patient and family needs and goals resulting in noncompliance with the following five Conditions of Participation: - §418.56 Condition of participation: Interdisciplinary group, care planning, and coordination of services;- §418.64 Condition of participation: Core services;- §418.78 Conditions of participation: Volunteers;- §418.100 Condition of Participation: Organization and administration of services; and- §418.104 Condition of participation: Clinical records. During an interview on 11/21/2024 beginning at 10:41 AM, the administrator stated that: - The current quality improvement/process improvement process had failed to identify documentation deficiencies; - That staff education was already scheduled to address care planning, coordination, and documentation issues; and- The provider had a current, active improvement process to address the insufficient number of volunteer hours served.”

“Based on policy review, current survey findings, and interview, the hospice provider failed to ensure the administrator was responsible for the day-to day operations of the organization.This deficient practice has the potential to affect all patients on service with the provider. Findings included:Review of the document titled, “;Governing Body,” last revised 09/01/2024, showed in part that the governing body was responsible for appointing a qualified administrator that is responsible for the day-to-day operations of the organization. The current survey findings showed the hospice administrator failed to effectively manage the overall day-to-day operations of the provider resulting in noncompliance with the following five Conditions of Participation: - §418.56 Condition of participation: Interdisciplinary group, care planning, and coordination of services;- §418.64 Condition of participation: Core services;- §418.78 Conditions of participation: Volunteers;- §418.100 Condition of Participation: Organization and administration of services; and- §418.104 Condition of participation: Clinical records. During an interview on 11/21/2024 beginning at 10:41 AM, the administrator stated that: - Staff education was already scheduled to address care planning, coordination, and documentation issues; and- The provider had a current, active improvement process to address the insufficient number of volunteer hours served.”

“Based on policy review, record review, home visit observation, and interview, the hospice provider failed to ensure the clinical record contain physician orders for the care and treatment of the patient in two of five full records reviewed (Records/Patients #1 and #2). This deficient practice has the potential to affect all patients served by the provider. Findings included:Review of the providers policy titled, “;Scope of Services,” last revised 03/24/2024, showed in part the provider will ensure that all services are provided in a manner consistent with accepted standards of practice. Review of the providers policy titled, “;Plan of Care Process,” last revised 09/01/2024, showed in part that:- The hospice nurse will review all medications and treatments with the attending physician and document orders within the initial plan of care and/or physician orders; and- All medication orders will be documented on the medication profile.Review of the undated document titled, “;Title of Position: Registered Nurse/Case Manager,” showed in part, that the nurse was responsible for providing nursing services, treatments, and preventative procedures as ordered by the physician RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice care on 09/18/2024 with a terminal diagnosis of Osteomyelitis (a bone infection) of the lumbar spine, and secondary diagnosis which included chronic kidney disease, (a condition where the kidneys gradually lose the ability to filter waste products from the blood), and senile dementia (a progressive disease that destroys memory and other important mental functions). The patient resided at home with a Primary Care Giver (PCG). Review of the initial, comprehensive nursing assessment completed on 09/18/2024 failed to list Durable medical equipment (DME). Observation and interview on 11/19/2024 starting at 9:00 AM, showed the following: - The patient was taking Senna Plus (stool softener); - The patient had a walker, a wheelchair, a Rollator (mobility aid that helps people with walking difficulties), and a bedside commode present. Review of the clinical record failed to show a physicians order for the Senna Plus, walker, wheelchair, Rollator, and bedside commode. During an interview on 11/21/2024 at 10:30 AM the administrator and governing body appointee 1 stated that there should be a physician’s order for the Senna Plus, and all DME in current use should be listed on the POC. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice service on 07/05/2024 with a primary diagnosis of hypertensive heart disease with chronic congestive heart failure (CHF; a decrease in the ability of the heart to pump blood), and chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient resided with his/her spouse in the home. Review of the skilled nursing (SN) visit dated 09/26/2024, showed the patient complained of increased wetness discharge, vaginal redness with yeast like discharge. Nystatin powder (used to treat fungal or yeast infections of the skin) was applied. Review of the providers “;Stand Down” notes (the providers email communication system) dated 09/26/2024, showed vaginal redness and nystatin cream was applied. Review of the providers “;Stand Down” notes dated 09/30/2024, showed the SN changed the foley catheter (a sterile tube placed in the bladder to drain urine). The patient was “;pretty” red and irritated. The SN completed peri care and nystatin applied. The SN failed to specify the application of nystatin cream or powder. Review of the clinical record failed to show a physician order for nystatin cream and the foley catheter change.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure documentation was accurate and complete in four of five full records reviewed (Records/Patients #1, #2, #4, and #5). This deficient practice has the potential to affect all patients served by the provider. Findings included:Review of the undated document titled, “;Title of Position: Registered nurse/Case Manager,” showed in part that the nurse must submit complete, accurate, and relevant clinical notes. Review of the providers undated policy titled, “;Approved Abbreviations and Symbols,” failed to contain the abbreviation “;MWT.” RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice care on 09/18/2024 with a terminal diagnosis of Osteomyelitis (a bone infection) of the lumbar spine, and secondary diagnosis which included chronic kidney disease, (a condition where the kidneys gradually lose the ability to filter waste products from the blood), and senile dementia (a progressive disease that destroys memory and other important mental functions). The patient resided at home with a Primary Care Giver (PCG). Review of the Social Work (SW) psychosocial assessment narrative notes, dated 09/19/2024, 10/15/2024, 10/21/2024, 10/22/2024, and 11/12/2024 showed in part the PCG was at the pharmacy when staff arrived and when the PCG returned indicated the patient had not slept. This verbiage was repeated exactly the same in all five notes. (This indicated the notes were either copied and pasted or carried forward with each visit, which would not necessarily make those notes accurate for each visit). During an interview on 11/21/2024 at 10:30 AM, the administrator and governing body appointee 1 stated: - Portions of the social worker assessment notes were identical in nature; and - The assessment notes should accurately describe the patient’s condition at the time of the assessment. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice service on 07/05/2024 with a primary diagnosis of hypertensive heart disease with chronic congestive heart failure (CHF; a decrease in the ability of the heart to pump blood), and chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient resided with his/her spouse in the home. Review of the initial comprehensive assessment dated 07/05/2024, showed the patient had a foley catheter (a sterile tube placed in the bladder to drain urine). Review of the plan of care (POC; which was part of the clinical record) dated 07/05/2024 and 07/12/2024, failed to be accurate and show the patient had a foley catheter. RECORD/CLIENT #4: Review of the clinical record showed the patient was admitted to hospice service on 10/16/2024 with a primary diagnosis of Parkinsons disease without dyskinesia, without mention of fluctuations (a neurological disorder that causes unintended or uncontrollable movements or stiffness, but currently without involuntary muscular movements or fluctuations). The patient resided with his/her spouse in the home. Review of the initial comprehensive assessment dated 10/16/2024, showed in part: - The patient was incontinent of bowel and bladder and wore incontinent products at all times; - Did not use a foley catheter; and - Did not use tube feeding. Review of the POC dated 10/18/2024 showed the patient/caregiver were able to administer tube feeding and provide care for tube insertion site. This was not accurate as the patient did not have a tube feeding. Also, the POC failed to be accurate and show the patient was incontinent. Review of the skilled nurse (SN) visits, dated 10/17/2024, 10/22/2024, 10/25/2024, 10/29/2024, 11/01/2024, 11/04/2024, 11/07/2024, 11/11/2024, and 11/14/2024, showed the patient needs “;MWT” in the home. Review of the providers undated “;Approved Abbreviations and Symbols” failed to show the abbreviation “;MWT.” Review of the POC dated 11/01/2024, showed the patient had an incontinent goal as the patient/caregiver understood proper care of the indwelling catheter and patient received proper care of the indwelling catheter. This was not accurate as the patient did not have an indwelling catheter. During an interview on 11/20/2024 at 10:30 AM, the administrator was not familiar with the abbreviation “;MWT.” During the exit interview the administrator, stated that the nurses entry should have been “;met”, to indicate the patients needs were met. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 09/20/2024 with a primary diagnosis of pancreatic cancer (the pancreas is an organ in the abdomen that produces hormones that regulate digestion and blood sugar levels). The patient had secondary diagnoses of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), diabetes (a group of diseases that results in too much sugar in the blood), and portal vein thrombosis (the formation of a blood clot in the veins of the liver). The patient resided in their own home with their spouse. Review of the document titled, “;RN Skilled Nursing Visit,” dated 10/08/2024 showed in part:- The patients respiratory status assessment: * Showed dyspnea with minimal exertion; * A productive cough of moderate amounts of thick, tan/yellow sputum; * The use of supplemental oxygen while sleeping; and - A care plan update showing the patient had no dyspnea or respiratory changes at this time. Review of the document titled, “;RN Skilled Nursing Visit,” dated 10/14/2024 showed in part:- The patients respiratory status assessment: * Showed dyspnea with minimal exertion; * A productive cough of moderate amounts of thick, tan/yellow sputum; * The use of supplemental oxygen while sleeping; and - A care plan update showing the patient had no dyspnea or respiratory changes. Review of the document titled, “;RN Skilled Nursing Visit,” dated 10/22/2024 showed in part:- The patients respiratory status assessment: * Showed dyspnea with minimal exertion; * A productive cough of moderate amounts of thick, tan/yellow sputum; * The use of supplemental oxygen while sleeping; and - A care plan update showing the patient had no dyspnea or respiratory changes. During an interview on 11/21/2024 at 10:44 AM, the administrator stated that:- They would expect the documentation to accurately reflect the patients condition; and- They did find inconsistencies in the respiratory assessment and care planning for this patient.”

“Based on record review and interview, the hospice provider failed to ensure a discharge summary was sent to the patients attending physician in two of two revocation records reviewed (Records/Patients #8 and #10). This deficient practice has the potential to affect the coordination of care of all patients who revoke the hospice benefit. Findings included: RECORD/PATIENT #8: Review of the clinical record showed in part, the following: - The patient elected hospice on 10/18/2024; - The patient and family made the decision to revoke hospice on 10/22/2024 to seek aggressive medical treatment and went to the emergency room; and - The provider failed to send a summary of the patient’s stay, the patients POC, current medication list or the latest physician orders to the emergency room physicians. RECORD/PATIENT #10: Review of the clinical record showed in part, the following: - The patient elected hospice on 07/14/2024; - The patient made the decision to revoke hospice on 08/29/2024 to seek aggressive medical treatment and went to the hospital; and - The provider failed to send a summary of the patient’s stay, the patients POC, current medication list or the latest physician orders to the hospital. During an interview on 11/20/2024 at 11:00 AM, the registered nurse (RN) coordinator stated that he/she did not have anything to show the discharge summary, the patients POC and the latest physician orders were sent to the hospital. He/she was not aware they were required to document that a discharge summary of care was sent to the receiving hospital. During an interview on 11/21/2024 at 10:00 AM, the RN/regional executive director (governing body appointee; GBA)-A, stated that he/she would expect the provider to send the patients POC, current medication list, and summary of care to the hospital or attending physician when they discovered the patient revoked.”

“Based on policy review, record review, observation, and interview, the hospice provider failed to ensure that the hospice plan of care (POC) identified which provider was responsible for providing wound care to the left lateral ankle wound outlined in the hospice plan of care. This deficient practice has the potential to affect all hospice patients that reside in a long-term care facility (LTCF). Findings included: Review of the providers policy titled, “;Hospice Care in a SNF/NF (Skilled Nursing Facility/Nursing Facility) or ICF/IID (Intermediate Care Facility/Individuals with Intellectual Disabilities),” last reviewed 09/01/2024 showed: - A copy of the POC, which includes services furnished, will be provided to the facility; and - The POC will identify the care and services that are specifically needed and identify which provider is responsible for performing the respective functions that have been agreed upon and included in the POC. RECORD/PATIENT #3: Review of the clinical record showed the patient elected hospice on 05/03/2024 with a terminal diagnosis of cancer of the left breast. The patient lived in a LTCF. Observation on 11/19/2024 beginning at approximately 9:00 AM of the hospice record maintained at the LTCF, showed the document titled, “;Hospice/LTC (Long-Term Care) Coordinated Task Plan of Care,” first dated 05/03/2024, showed “;Wound Care Schedule,” space was filled with previously discontinued wound care orders and had a a hand-written entry [See Back]”. The back of the document contained a hand-drawn grid that showed the following: - A hand-written entry with a start date of 11/15/2024, left lateral ankle cleanse with wound cleanser, pat dry, apply skin prep to peri wound area. Apply Santyl (a chemical agent used to remove dead tissue from a wound), nickel thick, to slough covered wound bed. Back with calcium alginate, secure with foam dressing, change daily and as needed if soiled or dislodged; and - The hand-written entry failed to identify which provider was responsible for performing the dressing change. During an interview on 11/21/2024 at 10:00 AM, the administrator stated that he/she would expect the coordinated task plan of care to be up-to-date and delineate which provider was responsible for performing the interventions.”

“Based on policy review, record review, home visit observation, and interview, the hospice provider failed to ensure the long-term care facility (LTCF) hospice patient record contained a copy of all required hospice documents in one of one applicable record of patients that resided in a LTCF (Record/Patient #3). This deficient practice has the potential to affect all hospice patients that reside in a LTCF. Findings included: Review of the providers policy titled, “;Hospice Care in a SNF/NF (Skilled Nursing Facility/Nursing Facility) or ICF/IID (Intermediate Care Facility/Individuals with Intellectual Disabilities),” last reviewed 09/01/2024, showed the hospice will provide the facility with the following hospice information/documentation on admission and on-going: - The hospice election form and any advance directives specific to each patient; - The physician certification and recertification of the terminal illness specific to each patient; and - The names and contact information for the hospice personnel involved in the care of each patient. RECORD/PATIENT #3: Review of the clinical record showed the patient elected hospice on 05/03/2024 with a terminal diagnosis of cancer of the left breast. The patient lived in a LTCF. Observation on 11/19/2024 beginning at approximately 9:00 AM of the hospice record maintained at the LTCF, showed the hospice binder failed to contain: - The hospice election form; - The physician certification and re-certification; and - The names of hospice personnel currently involved in the patients care. Per an interview, immediately after the home visit, the LTCF charge nurse stated that the hospice binder was where all hospice documents were kept. There was no online access for the staff to view the missing documents. During an interview on 11/21/2024 at 10:00 AM, the administrator stated that they send the documents to the LTCF but he/she was not sure who at the LTCF had access to them. He/she would expect all LTCF staff to have access to the required documents. He/she was not sure if the LTCF staff knew where to look. They would check into the issue. The goal was for the information to be accessible to the LTCF staff.”