Pruitthealth Hospice - Rocky Mount

“Based on agency policy, clinical record review, and staff interviews, the agency failed to document patient falls in the agency’s Incident/Occurrence Report for 2 of 2 patients reporting falls (patient #1 & 3).Findings included: A policy, Opportunity Occurrence Program for Hospice (revised 11/22/2021), received on 02/17/2026 at 11:58 AM from the administrator stated, “Mandatory Reportable Accidents/Incidents: All falls witnessed and not witnessed by a staff member…”1. Patient #1 was admitted on 12/12/2025 with a diagnosis of Alzheimer’s disease (brain degeneration). Patient #1 was a facility resident. The plan of care for 12/12/2025-03/11/2025 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 12 weeks, 1 time a week for 1 week, and 3 PRN (as needed). Review of the clinical record revealed that on 12/16/2025 registered nurse (RN) #3 documented a Late Entry note for 12/12/2025 stating, “Received a call from _______ [facility medication tech’s name] regarding patient having a fall after admission visit…” Review of the agency incident/occurrence report revealed that the fall was not documented.An interview conducted on 02/17/2026 at 11:38 AM 02/17 RN #3 revealed that they could not remember if they completed an incident report. Review of the agency incident/occurrence report revealed that the fall was not documented. 2. Patient #3 was admitted on 01/09/2026 with a diagnosis of Parkinson’s disease (degenerative disorder effecting the central nervous system). Patient #3 was a facility resident. The plan of care for 01/09/2026-04/08/2026 included orders for skilled nurse visits 2 times a week for 12 weeks with 3 PRN (as needed). Review of the clinical record revealed that on 02/03/2026 RN#5 documented, “Received a call from ______ [spouse’s name] that ______ [patient’s name] had fallen…” Review of the agency incident/occurrence report revealed that the fall was not documented.During an interview conducted on 02/17/2026 at 3:06 PM RN #5 stated, “I did not [complete an incident report] ________ [software system for documentation] didn’t allow me to do it. It [incident report] should have been completed the next day” During an interview conducted on 02/17/2026 at 11:48 the administrator stated, “My expectation is that an incident report is completed.””

“Based on agency policy, clinical record review, and staff interviews, the agency failed to provide an after-hours skilled nurse visit after a reported fall for 1 of 2 patients with a documented fall.Findings included: A policy, Patient Rights and Responsibilities for Hospice (reviewed 06/07/2021), received on 02/17/2026 at 9:55 AM from the administrator stated, “Patient, Legal Representative, and Caregiver Have the Right to… Expect twenty-four-hour, seven days a week, on-call services.”Patient #1 was admitted on 12/12/2025 with a diagnosis of Alzheimer’s disease (brain degeneration). Patient #1 was a facility resident. The plan of care for 12/12/2025-03/11/2025 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 12 weeks, 1 time a week for 1 week, and 3 PRN (as needed). Review of the clinical record revealed that on 12/16/2025 registered nurse (RN) #3 documented a Late Entry note for 12/12/2025 stating, “Received a call from_________ [facility medication tech’s name], regarding patient having a fall after admission visit…” Further review revealed that a PRN visit to assess for injuries after the fall was not documented.During an interview conducted on 02/17/2026 at 11:38 AM 02/17 RN #3 stated, “The policy states that we need to make a visit if the patient does fall.”During an interview conducted on 02/17/2026 at 3:50 PM the area vice president stated, “The Hospice nurse should have contacted the DHS [director of health services] and make a visit.””

“Based on agency policy, clinical record review, and staff interviews, the agency assigned interventions in the plan of care to disciplines who were not qualified to perform them for 3 of 23 patients. (#4, 7, 22)Findings included: 3. Patient #4 was admitted on 09/09/2025 with a diagnosis of chronic kidney disease stage 5 (kidney failure). The plan of care for 09/09/2025 - 12/07/2025 included orders for skilled nurse (SN) visits 2 times a week for 1 week, 3 times a week for 12 weeks, “patient declined volunteer services…”, “patient declined social work…”, and “Teach [patient nickname] regarding medications and medication management: SN, MSW [medical social worker], Volunteer, Chaplain”, “Assess for signs/symptoms of urinary tract infection: SN, MSW, Volunteer, Chaplain”, “Assess for presence of peripheral edema: SN, MSW, Volunteer, Chaplain”, “Assess [patient’s nickname] risk for developing pressure ulcers: SN, MSW, Volunteer, Chaplain”, “Assess pressure ulcer status including s/s [signs/symptoms] of healing and complications: SN, MSW, Volunteer, Chaplain”.During an interview conducted on 10/07/2025 at 11:52 AM the area vice president stated, “Chaplain’s and social workers should not be doing education on skilled nurse care” and confirmed that volunteers cannot assess or teach on skilled nursing care. A policy, Plan of Care for Hospice (revised 03/11/2022) received on 10/06/2025 at 12:57PM from the agency director stated, “Each patient and his or her primary caregiver(s) receive education and training from the hospice as appropriate to their responsibilities for the care and services provided in the plan of care.”1. Patient #7 was admitted on 09/11/2025 with a diagnosis of malignant neoplasm (cancer) of larynx (organ in neck holding the vocal cords). The plan of care included orders for skilled nurse (SN) visits 1 time a week for 1 week, 2 times a week for 8 weeks with 3 PRN, medical social worker (MSW) visits 1 time a month for 2 months with 4 PRN (as needed), Chaplain to assess and evaluate, and “Teach tracheostomy [artificial opening in the neck for breathing] care, cleaning (site assessment/cleaning, care of inner cannula, dressings, coughing/suctioning) during each visit document education and response: SN, MSW, Chaplain.”An interview conducted on 10/07/2025 at 11:38 AM with registered nurse #10 revealed that they believe that it is appropriate for the MSW and Chaplain to provide education on tracheostomy care.2. Patient # 22 was admitted on 07/11/2025 with a diagnosis of liver cell carcinoma (liver cancer). The plan of care for 07/11/2025-07/08/2025 included orders for skilled nurse (SN) visits 2 times a week for 12 weeks with 3 PRN (as needed), medical social worker (MSW) visits 2 times a month for 2 months with 3 PRN, “patient declined Chaplain services…”, and “Teach [patient nickname] regarding the contents and use of the comfort pack including morphine [narcotic medication] for pain and shortness of breath, as well as Zofran [treats nausea] for nausea related to liver cancer.: SN, MSW, Chaplain.”During an interview conducted on 10/07/2025 at 11:52 AM the area vice president stated, “Chaplain’s and social workers should not be doing education on skilled nurse care.””

“Based on agency policy, clinical record review, and staff interviews, the agency failed to include orders for suctioning for 1 of 1 patient requiring suctioning (patient #7), a CPAP (continuous positive airway pressure machine used to keep the airway open during sleep) for 2 of 2 patients with a CPAP (patients #’s 6 &10), complete orders for urinary catheters (tube that drains urine from the bladder) for 2 of 4 patients with urinary catheters (patient #’s 3 & 18), and failed to include oxygen orders for 4 of 7 patients with oxygen (patient #s 3, 6, 8, & 23).Findings included: 7. Patient #12 was admitted on 6/20/2025 with a diagnosis of Malignant carcinoid tumor of the transverse colon (colon cancer). The plan of care for 9/18/25– 12/16/25 included orders for skilled nursing 2 times a week for 12 weeks, and 5 PRN (as needed) visits for symptom management and “O2 [oxygen] @2L [liters per minute] prn [as needed] for shortness of breath”.A review of the clinical record revealed that oxygen was not listed as a medication on the patient’s plan of care. On 10/9/25 at approximately 11:00 AM, the area vice president confirmed that oxygen should be on the plan of care medication list. A policy, Plan of Care for Hospice (revised 03/11/2022) received on 10:06 AM at 12:57 PM from the administrator stated, “The patient’s plan of care specifies the care and services necessary to meet the needs of the patient/caregiver as identified in the initial, comprehensive and updated assessments of the patient.”1. Patient #7 was admitted on 09/11/2025 with a diagnosis of malignant neoplasm (cancer) of larynx (organ in neck holding the vocal cords). The plan of care included orders for skilled nurse (SN) visits 1 time a week for 1 week, 2 times a week for 8 weeks with 3 PRN. Review of the clinical record revealed that on 09/11/2025 registered nurse (RN) #10 documented, “Patient denies offer for suction…” Further review revealed that there was no order for suctioning in the plan of care.During an interview conducted on 10/07/2025 at 11:38 AM RN #10 stated that they did offer to suction the patient and confirmed that they did not have an order to suction.An interview conducted on 10/07/2025 at 11:40 AM with the area vice president revealed that the expectation is to have an order.2. Patient #6 was admitted on 09/02/2025 with a diagnosis of chronic obstructive pulmonary disease (lung disease restricting air flow). The plan of care for 08/22/2025-11/19/2025 included orders for skilled nurse visits 1 time a week for 11 weeks with 3 PRN (as needed). Review of the clinical record revealed that during the registered nurse (RN) visit on 09/03/2025 RN #17 documented, “SOB [shortness of breath] treatment O2 [oxygen] 2Lmin [liters per minute] NC [nasal cannula]” and on 09/29/2025 RN #17 documented, “Wears c-pap (continuous positive airway pressure machine used to keep the airway open during sleep) when sleeping.” Further review revealed that there were no orders for oxygen or a CPAP in the plan of care.3. Patient #10 was admitted on 10/02/2025 with a diagnosis of “Traum subdr hem with LOC status unknown, sequela” (head injury with internal bleeding). The plan of care for 10/02/2025 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 12 weeks with 5 PRN (as needed). During the registered nurse (RN) visit on 10/02/2025 RN #18 documented, “Findings/Treatments CPAP/BiPAP [Bilevel positive airway pressure, assist with respirations while sleeping].” Further review revealed that there was no order for a CPAP/BiPAP in the plan of care.An interview conducted on 10/08/2025 at 9:52 AM with the area vice president revealed that there were no orders in the plan of care for a CPAP/BiPap and should be.4. Patient #3 was admitted on 08/28/2025 with a diagnosis of chronic systolic (congestive) heart failure (heart can not pump enough blood through the body). The plan of care for 08/28/2025-10/26/2025 included orders for skilled nurse visits 1 time a week for 1 week, 3 times a week for 8 weeks with 3 PRN (as needed), “SP cath [suprapubic catheter, tube inserted through the abdomen into the bladder] should be changed every 4-6 weeks…” and “Change foley [catheter brand] catheter as ordered: on the first of each month” and “Oxygen.” Review of the clinical record reveal that there were no orders that included the size of the catheter or the dose of the oxygen.5. Patient #18 was admitted on 08/22/2025 with a diagnosis of Parkinson’s disease (progressive neurological disorder). The plan of care for 08/22/2025-11/18/2025 included orders for skilled nurse visits 1 time a week for 13 weeks with 3 PRN (as needed). Review of the clinical record revealed that on 09/01/2025 registered nurse (RN) #19 documented, “Urinary catheter.” Further review revealed that were no orders for a urinary catheter.During an interview conducted on 10/08/2025 at 4:27 PM the administrator stated, “There should always be an order for a catheter if the patient has one.”6. Patient #8 was admitted on 09/03/2025 with a diagnosis of malignant neoplasm of right breast (breast cancer). The plan of care for 09/03/2025-12/01/2025 included orders for skilled nurse visits 1 time a week for 12 weeks. Review of the clinical record revealed that on 09/03/2025 registered nurse (RN) #23 documented, “Oxygen 100% at rest with oxygen.” Further review revealed that there was no order for oxygen.During an interview conducted on 10/09/2025 at 11:18 AM RN #23 stated, “She should have an order [for oxygen] … I don’t see it… it [oxygen order] would go on medications.”An interview conducted on 10/08/2025 at approximately 11:00 AM with the area vice president revealed that the expectation is for the oxygen orders to be included in the medication profile.”

“Based on agency policy, clinical records review, and staff interviews, the agency failed to provide services as ordered in the plan of care for 2 of 18 active patients. (patients #7 & 11)Findings included: 2. Patient #11 was admitted on 08/20/2025 with a diagnosis of hemiplegia (a condition that causes paralysis or weakness on one side of the body). The plan of care included orders for skilled nurse (SN) visits 1 time a week for 1 week, 2 times a week for 13 weeks with 5 prn (as needed) visits, hospice aide 1 time a week for 1 week, 2 times a week for 13 weeks.A review of the clinical record revealed that the patient was only seen 1 time a week by the hospice aide during the week of 9/1/25 and 9/15/25 and no missed visit notes were documented.An interview conducted on 10/08/2025 at 2:48 PM with the area vice president confirmed that 2 hospice aide visits were missed. A policy, Plan of Care for Hospice (revised 03/11/2022) received on 10/06/2025 at 12:57 PM from the administrator stated, “It is the policy of [agency name] to make certain that the care and services provided to patients and their families are in accordance with an individualized, written plan of care…”Patient #7 was admitted on 09/11/2025 with a diagnosis of malignant neoplasm (cancer) of larynx (organ in neck holding the vocal cords). The plan of care included orders for skilled nurse (SN) visits 1 time a week for 1 week, 2 times a week for 8 weeks with 3 PRN and “Volunteer to Assess and Evaluate.”Review of the clinical record revealed that on 09/29/2025 the volunteer coordinator documented that they were unable to contact the patient and, “volunteer declined.”An interview conducted on 10/08/2025 at 12:43 PM with the volunteer coordinator revealed that the volunteer coordinator had not spoken to the patient to offer volunteer services.During an interview conducted on 10/08/2025 at 12:50 PM the area vice president stated, “They should continue to follow-up [attempt to contact and offer services].””

“Based on agency policy, direct observation, and staff interviews, the skilled nurse and chaplain failed to follow acceptable infection control practices for 2 of 6 patients receiving home visits (#12 and #15).Findings included: A policy, Hand Hygiene for Hospice (reviewed 8/7/2024), received from the administrator on 10/06/2025 at 1:23 PM stated, “Indications for handwashing: … before and after direct patient skin contact”. A policy, Bag Technique for Home Health and Hospice (reviewed 9/18/2025) was received from the administrator on 10/06/2025 at 1:23 PM. The policy stated, “Perform hand hygiene before accessing the bag… If additional equipment or supplies are needed from the bag during the visit, the handwashing procedure must be repeated… Rewash hands before patient contact… perform hand hygiene after equipment use…Clean equipment and allow the equipment to dry… return the equipment to the clean side of the bag.” 1. Patient #12 was admitted on 6/20/2025 with a diagnosis of Malignant carcinoid tumor of the transverse colon (colon cancer). The plan of care for 9/18/25 – 12/16/25 included orders for skilled nursing 2 times a week for 12 weeks, and 5 PRN (as needed) visits for symptom management. During a home visit at a skilled nursing facility conducted on 10/7/2025 at approximately 10:30 AM with registered nurse (RN) # 4, RN #4 washed hands with soap and water upon entering patient’s room. She removed the thermometer from the clinical bag, assessed the patient’s temperature, and placed thermometer back into the bag. RN #4 removed the stethoscope and the blood pressure cuff from clinical bag, assessed the patient’s blood pressure, and returned the stethoscope and blood pressure cuff to bag. RN #4 removed the pulse oximeter from clinical bag, assessed the oxygen saturation, then returned pulse oximeter to bag. Hand hygiene nor disinfection of the equipment occured prior to entering and reentering bag. An interview was conducted with RN #4 on 10/8/2025 at 11:51 AM. RN #4 stated “I disinfect the equipment after each patient use at least 10-15 minutes before I see the next patient…”2. Patient #15 was admitted on 6/12/2025 with a diagnosis of Alzheimer’s disease (a progressive disorder that affects memory, thinking, and behavior). The plan of care for 8/11/25 -10/09/25 included orders for Chaplain visits 1 time a month for 2 months and 3 PRN (as needed) visits.During a joint visit with Chaplain #6 on 10/7/25 at approximately 12:10 PM (patient resided in a skilled nursing facility), Chaplain #6 was observed placing his documentation device directly on the floor without any type of barrier. The chaplain used the device during the visit and did not disinfect at any time during the visit. After the visit, Chaplain #6 carried the documentation device to the facility nurse’s desk and placed it on the desk without a barrier. He then proceeded to clean only the screen of the documentation device with a disinfecting wipe. An interview was conducted on 10/9/2025 at 12:10 PM with Chaplain #6 and the area vice president. Chaplain #6 revealed that while he was trying to accommodate seating for everyone, he placed the tablet on the floor and would not normally do that.”

“Based on agency policy, clinical record review, and staff interviews, the agency documented licensed practical nurse (LPN) supervisory visits prior to the LPN visiting the patient for 1 of 10 patients with LPN supervisory visits. (patient #2) Finding included: A policy, Clinical Records for Hospice (revised 09/18/2024) received on 10/06/2025 at 1:32 PM from the administrator stated, “It is the policy of [agency name] to establish and maintain a clinical record for every patient receiving care and services and that record is to be complete, promptly, and accurately documented…”Patient #2 was admitted on 09/06/2025 with a diagnosis of Alzheimer’s disease (progressive brain disorder). The plan of care for 09/06/2025-12/04/2025 included orders for skilled nurse visits 1 time a week for 12 weeks. Review of the clinical record revealed the following documentation:On 09/15/2025 registered nurse (RN) #24 documented, “LPN Supervisory Visit Details [LPN #24’s name] … Client Satisfied Yes.”On 09/29/2025 registered nurse #24 documented, “LPN Supervisory Visit Details [LPN #24’s name] … Client Satisfied Yes.”Further review revealed that LPN #24 had not conducted a visit for patient #2.During an interview conducted on 10/08/2025 at 1:00 PM RN #23 stated, “It is in fact not possible [to document a supervisory visit prior to the LPN seeing the patient].””

“Based on agency policy, clinical record review, and staff interviews, the registered nurse failed to perform hospice aide supervisory visits every 14 days on 1 out of 15 patients with hospice aide orders. Findings included: A policy, Hospice Aide Assignments and Duties (reviewed 8/07/2024) was received from the administrator on 10/06/2025 at 1:26 PM. The policy stated “A registered nurse makes an on-site visit to the patient’s home no less frequently than every 14 days to assure that the services ordered by IDG and provided by the hospice aide are meeting the patient’s need.”Patient #1 was admitted on 8/28/2025 with a diagnosis of malignant neoplasm of unspecified bronchus or lung (lung cancer). The plan of care dated 8/28/25 – 11/25/25 included orders for skilled nursing 2 times a week for 13 weeks, and 5 PRN (as needed) visits for symptom management and hospice aide 2 times a week for 13 weeks. A review of the clinical record revealed that hospice aide supervisory visits were due by 9/15/25 and again by 9/29/25 in order to follow policy.An interview was conducted on 10/07/2025 at 9:30 AM with the area vice president, who confirmed that the hospice aide supervisory visits were not completed.”

“Based on agency policy, clinical record review, and staff interviews, the agency documented an advance directive as do not resuscitate for 1 of 2 patients that had requested to remain a full code. (patient #7)Findings included: A policy, Advanced Directives for Hospice, (09/09/2025) received on 10/06/2025 at 12:44 PM from the agency director stated, “The hospice nurse or social worker documents in the patient’s clinical record that written information was provided and whether the patient has executed an advance directive.”Patient #7 was admitted on 09/11/2025 with a diagnosis of malignant neoplasm (cancer) of larynx (organ in neck holding the vocal cords). The plan of care included orders for skilled nurse (SN) visits 1 time a week for 1 week, 2 times a week for 8 weeks with 3 PRN and “Advanced Directives/Healthcare Proxy Full resuscitation.” Review of the clinical record revealed the following documentation:On 09/11/2025 RN (registered nurse) #10 documented, “Does the patient want CPR [cardiopulmonary resuscitation] if heart or lungs stop working? No… DNR [do not resuscitate] order.”For the interdisciplinary group meeting on 09/18/2025 RN #10 documented, “DNR.”On 09/17/2025 RN #9 documented, “DNR.”On 09/19/2025 RN #9 documented, “DNR.”On 09/26/2025 RN #9 documented, “DNR.”On 10/01/2025 RN #9 documented, “DNR.”On 10/03/2025 RN #9 documented, “DNR.”Further review revealed that there was no documentation of patient #7 having a DNR order.During an interview conducted on 10/07/2025 at 11:38 RN #10 stated, “We did talk about code status, he did not want chest compressions. I made team aware that he would need a golden rod [DNR form]. I put in the order for a DNR… I am not seeing the DNR order either…”During an interview conducted on 10/07/2025 at 11:55 AM RN #9 stated, “His code status is a full code. I do be forgetting that he’s a full code.”During an interview conducted on 10/07/2025 at 12:00 PM the area vice president stated, “That it [code status] should be reviewed at every visit and documented accurately.””

“Based on agency policy, clinical record review, and staff interviews, the skilled nurse failed to communicate a change in condition with the provider for 1 out of 18 active patient records reviewed.Findings included: A policy, Coordination of Hospice Services (reviewed 8/21/2024), was received from the administrator on 10/06/2025 at 1:26 PM. The policy stated “An assigned hospice RN [registered nurse] coordinates the patient’s plan of care and facilitates the ongoing sharing of information with the attending physician, contracted facilities…”Patient #14, who resides at a skilled nursing facility, was admitted on 9/23/2025 with a diagnosis of Senile degeneration of brain (a progressive decline in cognitive abilities that occurs with aging). The plan of care dated 9/23/25 – 12/21/25 included orders for skilled nursing 2 times a week for 13 weeks, and 5 PRN (as needed) visits for symptom management. A review of the clinical record revealed that on 10/6/25, licensed practical nurse (LPN) #15 documented “CNA [certified nursing assistant] reported that the patient had bright red blood in his stool….RN case manager (RN #4) was updated regarding findings…” LPN #15 documented that an attempt was made to inform the facility nurse practitioner but was unable to reach by phone. An interview was conducted on 10/08/2025 at 11:45 AM with RN #4, who confirmed that LPN #15 had notified her of the blood in the patient’s stool and she did not notify the hospice physician, facility physician, or patient’s family. An interview was conducted with LPN #15 on 10/09/25 at 10:34 AM, who confirmed that she had tried to notify the facility nurse practitioner, but was not able to reach her by phone. She passed this information on to RN #4, presuming RN #4 would notify the Hospice physician.During an interview conducted on 10/08/2025, the area vice president stated that the expectation is that the physician and family should be notified in the case of a change in patient condition.”

“Based on agency policy, clinical record review, and staff interviews, the agency failed to obtain consent from the patients representatives/power of attorneys prior to adding volunteer services to the plan of care for 2 of 2 patients with orders for volunteers. (patients #1 and 2)Findings Included: A policy Patient Rights and Responsibilities for Hospice (reviewed 06/07/2021) received on 07/08/2025 at 11:30 AM from the administrator stated, “Patient, Legal Representative, and Caregiver Have the Right to: Be fully informed of hospice services in advance so that decisions concerning your care can be made… Receive only the care and services to which you have consented.”Patient #1 was admitted on 12/03/2024 with a diagnosis of Unspecified sequelae cerebral infarction (interruption of blood flow to the brain with long term effects, weakness, difficulty speaking, understanding speech, difficulty with thinking, and reasoning.). The plan of care for 12/03/2024-03/02/2025 included orders for volunteer visits 1 time a month. Review of the clinical record revealed that on 12/04/2025 the volunteer coordinator documented, “I introduced myself and explained that we had some volunteers who would like to come out and see her. At first, she did not seem to understand… She said okay. Sometimes she would put her hand up in a confused gesture… At one point, she tried to point to me and communicate something but seemed to get frustrated and gave up… Frequency will be 1x [time] a month…” Volunteer visits were added to the plan of care. Further review revealed no documentation that the patient’s representative/caregiver were notified.Patient #2 was admitted on 09/25/2025 with a diagnosis of malignant neoplasm of the rectum. The plan of care for 09/25/2024-12/23/2024 included orders for volunteer visits 1 time a month beginning 09/30/2024. Review of the clinical record revealed that on 09/26/2024 the volunteer coordinator documented, “He said that if they [volunteers] want to come visit they can.” Review of the Notice of Election/Informed Consent document revealed that the patient’s son signed the consents as the legal representative because the patient was, “confused due to disease process” and could not provide consent. Further review revealed that there was no documentation of the patient’s legal representative being contacted prior to adding volunteers to the plan of care.The volunteer coordinator was not available for an interview.During an interview conducted on 07/08/25 at 10:57 AM the administrator confirmed that there was no documentation of the responsible party being notified of a volunteer being added to the plan of care and stated, “If the patient is unable to consent, they need to discuss it [changes to the plan of care] with the family member.””

“Based on agency policy, clinical record review, and staff interviews, the agency failed to develop an individualized plan of care for 1 of 3 patients with record reviews. (# 1, 2, 3).Findings included: A policy, Plan of Care for Hospice (reviewed 03/11/2022), received on 07/07/2025 at 3:19 PM from the administrator stated, “It is the policy of [agency name] to make certain that the care and services provided to patients and their families are in accordance with an individualized, written plan of care…”Patient #2 was admitted on 09/25/2024 with diagnoses of malignant neoplasm of the rectum (rectal cancer) and dysphagia (difficulty swallowing). The plan of care for 09/25/2024-12/23/2024 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 13 weeks with 10 PRN (as needed). Review of the plan of care revealed that there were no interventions included related to dysphagia. 2. Patient #3 was admitted on 08/22/2024 with diagnoses of Parkinsonism (a collection of movement symptoms) and vascular dementia (confusion caused by reduced blood flow). The plan of care for 02/18/2025-04/18/2025 included orders for skilled nurse visits 2 times a week for 8 weeks with 5 PRN and “dietary order: Regular puree.” Review of the clinical record revealed that on 02/24/2025 RN #10 documented, “severe dysphagia.” Review of the plan of care revealed that there were no interventions included related to dysphagia.An interview conducted on 07/08/2025 at 9:42 AM with RN #4 revealed that a patient with dysphagia should have a disease specific plan of care.An interview on 07/08/2025 at 10:36 AM with the administrator revealed that the expectation is for the plan of care to be updated with interventions related to dysphagia should be documented on the plan of care.”

“Based on agency policy, clinical record review, and staff interviews, the agency failed to communicate changes of condition/symptoms between all disciplines providing care and/or services for 1 of 3 patients with record reviews (1).Findings included: A policy, Coordination of Hospice Services (reviewed 08/21/2024), received on 07/08/2025 at 11:43 AM from the administrator stated, “It is the policy of [agency name] Interdisciplinary Group (IDG) to make certain that there is a coordinated and effective ongoing sharing of information amongst and between all disciplines…”Patient #1 was admitted on 12/03/2024 with a diagnosis of unspecified sequelae cerebral infarction (interruption of blood flow to the brain with long term effects). The plan of care for 12/03/2024-03/02/2025 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 13 weeks, with 6 PRN (as needed), Medical Social Worker (MSW) 1 times a month for 3 months with 6 PRN (as needed), and volunteer visits 1 time a month. Review of the clinical record revealed that on 12/04/2024 the volunteer coordinator documented, “Pt [patient] also seemed to have a cough.” On 12/16/2024 MSW #5 documented, “Pt [patient] was coughing and kept adjusting the pads underneath her as if she was uncomfortable. Further review revealed that there was no documentation in the clinical record of the volunteer coordinator or MSW #5 notifying the registered nurse.The volunteer coordinator was not available for an interview.MSW #5 was not available for an interview.An interview conducted on 07/08/2025 at 10:25AM with the administrator revealed that the expectation is for all agency staff to report symptoms to the registered nurse case manager.”

“Based on agency policy, clinical record review and staff interviews, the agency failed to obtain wound measurements for 1 of 2 patients with wounds. (#1)Findings included: A policy, Wound Documentation for Hospice (effective 10/01/2018), received on 07/07/2025 at 3:42 PM from the administrator stated, “All wounds will be measured weekly by the hospice nurse…”Patient #1 was admitted on 12/03/2024 with a diagnosis of unspecified sequelae cerebral infarction (interruption of blood flow to the brain with long term effects, weakness, difficulty speaking, understanding speech, difficulty with thinking, and reasoning.). The plan of care for 12/03/2024-03/02/2025 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 13 weeks with 6 PRN (as needed). Review of the clinical record revealed that on 12/04/2024 licensed practical nurse (LPN) #6 documented, “Diffuse stage II pressure areas [shallow open wounds] to bilateral sacrum spanning to lower buttocks…” Further review revealed that 6 of 6 SN visits had no documentation of wound measurements.LPN #6 was not available for an interview.An interview conducted on 07/07/2025 at 1:30 PM with the agency administrator confirmed that there was no evidence that the wound was ever measured. The agency administrator stated, “The registered nurse completes the wound measurements at every visit, at least once a week.””

“Based on agency policy, clinical record review, and staff interviews, the agency failed to provide an alternating pressure pad and pump [pressure relieving mattress] as ordered for 1 of 1 patient. (#1)Findings included: A policy, Durable Medical Equipment for Hospice (reviewed 07/31/2024), received on 07/08/2025 at 11:30 AM from the administrator stated, “It is the policy for [agency name] to provide for safe and effective use of medical equipment including delivery, setup, maintenance and training of staff, patients, family members and other caregivers.”Patient #1 was admitted on 12/03/2024 with a diagnosis of unspecified sequelae cerebral infarction (interruption of blood flow to the brain with long term effects). The plan of care for 12/03/2024-03/02/2025 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 13 weeks, with 6 PRN (as needed) and “DME: Alternating pressure pad and pump…. Start 12/04/2025.” Review of the clinical record revealed that on 12/18/2024 registered nurse (RN) #8 documented, “Son reiterated concerns about the oral care at the facility and delayed medical equipment. Son stated that hospital mattress was supposed to be delivered on 12/06 and had not yet arrived.”An interview conducted on 07/08/2025 at 10:09 AM with RN #8 confirmed that the patient did not have the mattress.An interview conducted on 07/08/2025 at approximately 10:20 AM with the administrator revealed that the mattress was ordered and it is the expectation for the nurse to confirm delivery. The administrator could not state when patient #1 received the mattress.”

“Based on agency policy, clinical record review, and staff interviews, the agency failed to accurately document physician’s orders for 2 of 3 patients with record reviews conducted. (patients #1, & 2)Findings included: A policy, Documentation requirements for Hospice (reviewed 08/07/2024) received on 07/08/2025 at 11:32 AM from the administrator stated, “Documentation must be legible, grammatically correct, accurate, and timely.”Patient #1 was admitted on 12/03/2024 with a diagnosis of Unspecified sequelae cerebral infarction (interruption of blood flow to the brain with long term effects, weakness, difficulty speaking, understanding speech, difficulty with thinking, and reasoning.). The plan of care for 12/03/2024-03/02/2025 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 13 weeks with 6PRN (as needed) and NPO (nil per os, Latin for nothing by mouth). Patient #1 had a gastrostomy tube (surgically placed device to access the stomach]. Review of the clinical record found the following medication orders:“Acetaminophen [treats pain] 325mg oral tablet; Take 2 tab(s) orally every 4 hours as needed for mild pain”“Gabapentin [treats nerve pain] 300mg oral capsule; Take 1 cap(s) orally 2 times a day.”“Geri-tussin expectorant [treats cough] 100mg/5mL oral liquid; Take 2.5 mL orally 3 times a day”“Hyoscyamine [dries secretions] 0.125 mg oral tablet; Take 1 tablet orally every 6 hours”“Levothyroxine [treats low thyroid hormone] 50 mcg oral capsule; Take 1 cap(s) orally once a day”“Lorazepam [treats anxiety] 0.5 mg oral tablet; Take 1 tab(s) orally every 6 hours”During an interview conducted on 07/08/2025 at 9:42 AM with registered nurse (RN) #4 stated, “Normally those medications should be order by tube [gastrostomy tube; surgically placed device to access the stomach]. I guess I made a mistake and ordered them by mouth.”During an interview conducted on 07/08/2025 at 9:48 AM the administrator stated, “The orders need to be clarified with a physician and changed as needed.” 2. Patient #2 was admitted on 09/25/2025 with diagnoses of malignant neoplasm of the rectum and retention of urine. Patient #2 was a resident of a skilled nursing facility. The plan of care for 09/25/2024-12/23/2024 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 13 weeks with 10 PRN (as needed) and “Catheter: Catheter care as needed. Change PRN per facility protocol for leakage, dislodgement, obstruction As Needed Indwelling urinary catheter #16F 10cc bulb.”During an interview conducted on 07/08/2025 at 9:45 AM RN #4 stated, “I know that the facility protocol is on the first on the month, I should have put that order in with a specific day to be changed.”An interview conducted on 07/08/2025 at 9:50 AM with the agency administrator revealed that the expectation is for the order to be entered with a specific frequency.””

“Based on agency policy, clinical record review, and staff interviews, the agency failed to develop an individualized plan of care for 3 of 3 patients with record reviews. (#1, 2, 3)Findings included: A policy, Plan of Care for Hospice (reviewed 03/11/2022), received on 07/07/2025 at 3:19 PM from the administrator stated, “It is the policy of [agency name] to make certain that the care and services provided to patients and their families are in accordance with an individualized, written plan of care…” Patient #1 was admitted on 12/03/2024 with a diagnosis of unspecified sequelae cerebral infarction (interruption of blood flow to the brain with long term effects, weakness, difficulty speaking, understanding speech, difficulty with thinking, and reasoning.). The plan of care for 12/03/2024-03/02/2025 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 13 weeks with 6 PRN (as needed), Aide visits 1 time a week for 1 week, 2 times a week for 12 weeks, NPO (nil per os, Latin for nothing by mouth), and “discontinue-effective 12/13/2024: NPO Puree diet with thin liquids.” A review of the clinical record revealed that on 12/12/2024 licensed practical nurse (LPN) #6 documented, “New order for pureed diet…” Further review revealed that the aide plan of care was not updated to include the new diet order.LPN #6 was not available for an interview.An interview on 07/08/2025 at 10:36 AM with the administrator revealed that the expectation is for the plan of care to be updated with a new diet order.”

“Based on agency policy, clinical record review, complaint log review, and staff interviews, the agency failed to document and investigate a complaint that was reported to the agency for 1 of 1 patient with a complaint. (patient #2) Findings included: A policy, Complaint Resolution for Hospice (reviewed 07/31/2024), received on 02/24/2025 at 5:11 PM from the agency administrator stated, “;All complaints are documented in a complaint log by the Director of Health Services or Administrator no more than 5 (five) business days from the date that the complaint was first received. Appropriate personnel conduct a documented investigation...” Patient #2 was admitted on 10/07/2024 with a diagnosis of neurocognitive disorder with Lewy bodies (condition causing changes in thinking, movement, behavior, and mood). The plan of care for 10/07/2024-01/04/2025 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 2 weeks, with 13 PRN (as needed) visits. A review of the clinical record revealed that the patients daughter revoked hospice services on 02/07/2025. A review of the agencys Complaint and Grievance Record Form for Hospice revealed that no complaint was documented for patient #2. An interview conducted on 02/25/2025 at approximately 4:40 PM with the agency director revealed that the patients daughter entered the agency and spoke with the office manager. During an interview conducted on 02/25/2025 at approximately 4:45 PM the office manager stated, “;She [patients daughter] said that we [hospice agency] were trying to kill her mother. I didnt log it as a complaint because she was revoking services.” During an interview conducted on 02/25/2025 at approximately 4:50 PM the agency director stated, “;We [hospice agency] should have documented a complaint, investigated, and reported it to compliance operations.””

“Based on agency policy, clinical record review, and staff interviews, the agency failed to manage symptoms related to the terminal diagnosis for 1 of 1 patient with unmanaged symptoms. (patients #2) Findings included: A policy, Patient Rights and Responsibilities for Hospice (reviewed 06/07/2021), received on 02/24/2025 at 5:11 PM from the agency director stated, “;Patient, Legal Representative, and Caregiver Have the Right to: ... Receive effective pain management and symptom control for conditions related to your terminal illness.” Patient #2 was admitted on 10/07/2024 with a diagnosis of neurocognitive disorder with Lewy bodies (a condition causing changes in thinking, movement, behavior, and mood). The plan of care for 10/07/2024-01/04/2025 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 2 weeks, with 13 PRN (as needed) visits. A review of the clinical record revealed the following documentation: During the registered nurse (RN) visit of 12/23/2024 RN #3 documented, “;She is no5 [sic] eating or drinking... she is throwing up what she has eaten... now she is throwing up ensure [supplement drink].” Further review revealed that there was no physicians order for medication to treat nausea or vomiting and the physician was not notified. During the RN visit of 01/03/2025 RN #5 documented, “;[Daughters name] reported watery stools for about a week...” Further review revealed that there was no physicians order for medication to treat liquid stools and the physician was not notified. During the RN visit of 01/06/2025 RN #3 documented, “;Patient rejects food most of the time but is unable to hold it down when she eats.” Further review revealed that the physician was not notified. During the RN visit of 01/08/2025 RN #3 documented, “;Patients daughter says that she started throwing up what she is drinking...” Further review revealed that the physician was not notified. An interview conducted on 02/24/2025 at approximately 4:00 PM with RN #3 revealed that the physician was not notified about unmanaged vomiting. An interview conducted on 02/24/2025 at approximately 3:18 PM with RN #5 revealed that the physician was not notified about the patients unmanaged diarrhea. An interview with the agency administrator on 02/24/2025 at 3:44 PM revealed that the expectation is for all unmanaged symptoms to be treated.”

“Based on clinical record review and staff interviews, the agency failed to include accurate medication orders for 1 of 3 patients. (patient #2) Findings included: Patient #2 was admitted on 10/07/2024 with a diagnosis of neurocognitive disorder with Lewy bodies (condition causing changes in thinking, movement, behavior, and mood). The plan of care for 10/07/2024-01/04/2025 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 2 weeks, with 13 PRN (as needed) visits, and an order dated 10/29/2024 for, “;Lorazepam [anxiety medication] 0.5 mg [milligrams] oral tablet; Take 0.50 milliliter(s) [measurement for liquid medications] oral every 4 to 6 hours as need for anxiety.” During an interview conducted on 02/24/2025 at 3:55 PM registered nurse #3 stated, “;The 0.5 [dose] should be in milligrams.” An interview conducted on 02/24/2025 at 4:15 PM with the agency administrator revealed that the expectation is for all medication doses to be documented accurately.”