New Century Hospice Inc.

“Upon patient record review, 1 of 14 (Patient #9) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #9 -Volunteer ordered 1 x a week, does not identify the scope i.e. socialization, errands,”

“Upon patient record review, 3 of 14 (Patient #6, 11, 12) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #6 -Initial assessment SN documented DNR but POLST signed 05/21/25 has Full Code. Patient #11 -SN completed Aide Supervisory visit on 06/03/25 - Aide first visit made 06/13/25. Patient #12 -Initial assessment SN documented CPR full code but POLST signed 05/27/25 has DNR.”

“Based on interview, record review, and policy review, the hospice agency failed to ensure a patient-specific initial and comprehensive assessment was completed for eight of 14 patients (Patient (P) P2, P3, P5, P6, P7, P9, P11, and P12) whose records were reviewed out of a total sample of 14. Specifically, the hospice failed to ensure the Social Worker Initial Assessment was done timely for P2, the drug profile was correct for P3, P5, P6, P7, P9, and P12, and a bereavement assessment was completed for P11. This deficient practice had the potential to adversely affect the quality of care, health, safety, and quality of life of the agency’s patients. Findings include: A review of P2’s electronic medical record (EMR) within the Assessment tab revealed the Social Worker Initial Assessment was completed 11 days after the date of the Hospice Election. A review of the EMR for P3, P5, P6, P7, P9, and P12 revealed medication discrepancies, and a review of P11’s EMR revealed that no Bereavement Assessment was completed. Refer to L524, L530, and L531.”

“Based on interview, record review, and policy review, the hospice agency failed to ensure that the hospice staff planned and provided the care and services necessary to meet the patient and family specific needs through the Interdisciplinary Group, Care Planning, & Coordination of Services for 14 of 14 patients (Patient (P) P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14) whose records were reviewed out of a total sample of 14. This deficient practice had the potential to adversely affect the quality of care, health, safety, and quality of life of all patients served by this agency. Findings include: 1. A review of P5 and P12’s “Interventions and Goals” and “Plan of Care Summary” sections located within the “Plan of Care” tab in the electronic medical record (EMR) revealed discrepancies in the content of the plan of care. 2. A review of P2 and P10’s “Nursing” section located within the “Assessments” tab of the EMR revealed a failure to ensure the initiation of interventions to manage pain and symptoms. 3. A review of P12 and P14’s “Plan of Care Summary” section located within the “Plan of Care” tab in the EMR revealed a lack of detailed scope and frequency. 4. A review of P1, P2, P3, P4, P5, P7, P8, P9, P10, P11, P13, and P14’s “Interventions and Goals” section located within the “Plan of Care” tab in the EMR revealed a lack of measurable outcomes. 5. A review of P6 and P8’s “Plan of Care Summary” sections located within the “Plan of Care” tab and the “Psychosocial” section located within the “Assessments” tab revealed failure to follow the prescribed plan of care. See L546, L547, L548, and L555.”

“Based on interview, record review, and policy review, the hospice agency failed to ensure that the only licensed and professional staff accepted and transcribed verbal orders for six of 14 patients (Patient (P) P5, P8, P9, P10, P12, and P14) whose records were reviewed out of a total sample of 14. This deficient practice had the potential to adversely affect the health and safety of the agency’s patients. Findings include: A review of P5, P8, P9, P10, P12, and P14’s medical records, located in the Physician tab in the electronic medical record (EMR), revealed inappropriately completed Physician Orders. See L678.”

“Based on record review and observation, the facility failed to ensure Emergency Preparedness drills and exercises were conducted according to regulations. Failure to follow theguidelines for conducting these drills has the potential for staff to be unaware of what their responsibilities are during an emergency and could lead to injuries. Findings include: Review of the facilitys Emergency Preparedness Plan indicated a Fire Drill was held on 01/15/24 and on 01/15/25 and an Earthquake drill was held 10/25/23 and on 10/25/24. Review of the analysis done after both Fire drills and Earthquake drills indicated the in-service training that should be done based on this analysis, was the same after each drill, both years. Further review of the Emergency Preparedness Plan indicated the names and numbers for community resources and other entities were listed as well as a telephone tree to alert staff. There was no indication that the facility had participated in any community-based drills or evidence that the facility attempted to join with any community entity for any emergency drills or exercises. During an interview with the Administrator, who is also in charge of the Emergency Preparedness Plan, on 02/13/25 at 6:00 PM, the Administrator said the facility staff participates in an online class called “;Shake Out” and they have done a Hazmat training online. The Administrator said the drill on 01/15/24 was a tabletop drill of a microwave on fire in the office, staff were notified not to come to the office as part of the drill. The Administrator said that during the Earthquake drill, patients and staff were called to do triage as to what everyone needed, walkie talkies were used to communicate. The administrator explained had invited the police and fire departments to come for in-service training, but it had not happened. Administrator advised the facility had not been actively searching for community resources to join with for drills and confirmed the drills for previous years had been the same topic. The Administrator said has not approached the local, large airport to join with because the airport is busy, the fire department would not join with them, and local community agencies are anxious to do group Emergency Preparedness exercises because they are still in the COVID frame of mind. When asked if Covid is active in the area administrator said no. The Administrator agreed that there was duplication of the drills in previous years and the Hospice needed to widen the variety of drills and exercises being done and try to be more active with the community.”

“Based on interview and record review, the hospice agency failed to ensure the patients under care were free from misappropriation of personal property for one of 14 patients (Patient (P) P8) whose records were reviewed out of a total sample of 14. This deficient practice had the potential to adversely affect the mental health, safety, and quality of life of the agency’s patients. Findings include: A review of P8’s electronic medical record (EMR) revealed a Communication Note, dated 10/31/24 and located within the Communication Notes tab of the EMR. This note recorded documentation of a phone call received by an agency employee from the Ombudsman completing a spot check at the group home where the patient resided. The patient had reported, “money was stolen by [his/her] [family member] . . .” The Communication Note further recorded, “Will refer the patient to the Social Worker.” There was no documented evidence this issue was communicated to the Medical Social Worker, nor was there any documentation by the Medical Social Worker recording this issue was addressed. An interview with the Administrator on 02/13/25 at 1:00 PM revealed this incident should have been followed up on and documented. The Administrator was unable to present validation of the report to a Medical Social Worker taking place or follow-up on this issue.”

“Based on interview and record review, the agency failed to ensure the Comprehensive Assessment identified the psychosocial needs of the patient no later than five calendar days after the election of hospice care for one of 14 patients (Patient (P) 2) whose records were reviewed out of a total sample of 14. This deficient practice had the potential to cause or perpetuate psychosocial and/or emotional distress, fail to identify patient or family needs for counseling and education, and affect the quality of care received by the agency’s patients. Findings include: A review of P2’s electronic medical record (EMR) within the Assessments tab revealed the Social Worker (SW) Initial Psychosocial Assessment was conducted on 02/26/24, 11 days after the start of care date. There was no evidence of documentation to explain this tardiness. The Comprehensive Nursing Assessment, dated 02/15/24 and located within the Nursing section of the Assessments tab, did not reveal any request to postpone or refuse the Psychosocial Assessment, nor was a Psychosocial Assessment completed by the visiting Registered Nurse (RN). The EMR did not contain a Communication Note documenting attempted contact by the SW or refusal of a visit for the Initial Psychosocial Assessment. The Medical Social Worker was not available during attempts to contact them for an interview. The Administrator was interviewed on 02/13/25 at 1:00 PM and reported no knowledge of refusal or further rationale for a late visit.”

“Based on interview and record review, the hospice agency failed to ensure complete and accurate drug profiles were maintained on 6 of 14 patients (Patient (P) 3, 5, 6, 7, 9, and 12) whose records were reviewed out of a total sample of 14. This deficient practice had the potential to affect health and safety through adverse events such as increased drug side effects, actual or potential drug reactions, and duplicate drug therapy for the agency’s patients. Findings include: 1. A review of P3’s Current Treatment/Medication/DME List, located within the tab with the same name, and the Physicians Order dated 10/07/24, located within the Physician tab in the electronic medical record (EMR) revealed an incomplete MiraLAX (bowel medication) order. The order read, Miralax Powder for Solution 17 grams (g) oral daily for constipation. There were no further instructions for diluent. During an interview with the Administrator on 02/13/25 at 1:00 PM, it was confirmed that agency policy and practice was to complete MiraLAX medication instructions with a diluent, typically eight ounces of water or beverage of choice. 2. A review of P5’s printed Plan of Care Summary, effective 02/11/25 and provided by the agency, revealed duplicate drug therapy and unlisted active medications. a. Hydrocodone Bitartrate/Acetaminophen (pain medication) 10 milligram (mg)-325 tablet, one tab every six hours as needed pain-severe, and Hydrocodone Bitartrate/Acetaminophen 10 mg-325 tablet, one tab four times daily as needed pain-moderate-severe. These medications are the same but have differing administration frequencies, resulting in duplicate drug therapy. b. Ondansetron (nausea medication) 4 mg, one tab oral four times a day, and ondansetron 4 mg, an orally disintegrating tablet, one tab oral four times per day, were present on the Plan of Care Summary. c. Primidone 250 mg, one tablet by mouth at bedtime, and Primidone 50 mg, four tablets by mouth before bedtime, were present on the Plan of Care Summary with no instructions indicating if these medications were duplicates or meant to be combined for a higher total dose. d. The medication reconciliation during the home visit on 02/11/25 at 12:30 PM also revealed that the patient took Folic Acid (supplement) 1 mg by mouth daily and Vitamin D3 (supplement) 1000 units by mouth daily. These medications were not found on the Plan of Care Summary. The patient and spouse both verified these findings during the home visit. 3. A review of P6’s printed Plan of Care Summary, effective 02/11/25 and provided by the agency, revealed discrepancies during medication reconciliation during the home visit on 02/11/25 at 11:00 AM. a. Medications listed on the Plan of Care Summary as active medications included Carafate (anti-ulcer medication), Docusate Sodium (bowel medication), Famotidine (acid reducer), Gabapentin (anticonvulsant), Hydrocortisone (steroid), Nitroglycerine (anti-anginal), and Plavix (anti-coagulant) but were not present in the home. The Registered Nurse (RN1) and the patient verified these findings during the home visit interview. b. Medications not listed on the Plan of Care Summary but present in the home include Apixaban (an anticoagulant), Lorazepam (an anti-anxiety medication), and Rosuvastatin (a cholesterol medication). The Registered Nurse (RN1) and the patient verified these findings during the home visit interview. 4. A review of P7’s printed Plan of Care Summary, provided by the agency, during the home visit on 02/11/25 at 2:30 PM revealed Lactulose (bowel medication)10 gm/15 ml solution with a dosage of 60 ml by mouth two times per day. This medication was present in the home. Lactulose 20 gm/30 ml with a dosage of 30 ml by mouth twice daily was also present in the home but was not on the patient’s Plan of Care Summary. The facility manager provided and verified the patient’s medication during the home visit. 5. A review of P9’s Plan of Care Summary, with an effective date of 02/12/25 and located within the Plan of Care tab of the EMR, reflected both Lorazepam (anti-anxiety) 2 mg by mouth daily at bedtime as needed and Ativan (anti-anxiety) 2mg by mouth at bedtime as needed. This was duplicate drug therapy. The Administrator reviewed and confirmed this as a duplicate medication during the interview on 02/13/25 at 1:00 PM stating, “They both should not be there. One is generic.” 6. A review of P12’s Plan of Care Summary, with an effective date of 02/13/25 and located within the Plan of Care tab of the EMR, recorded Acetaminophen (pain medication) 325 mg, two tabs by mouth mild pain. “Mild” was indicated as the frequency, and “pain” was the indication, with no further clarification on when or how often medication should be given. The Administrator reviewed and confirmed this was an error during the interview on 02/13/25 at 1:00 PM; verbalizing a frequency should be listed and not a pain rating.”

“Based on interview and record review, the agency failed to ensure the Comprehensive Assessment identified the Bereavement needs of the patient and/or family no later than five calendar days after the election of hospice care for one of 14 patients (Patient (P) 11) whose records were reviewed out of a total sample of 14. This deficient practice had the potential to cause or perpetuate psychosocial and/or emotional distress, fail to identify patient or family needs for counseling and education, and affect the quality of Bereavement Care received by the agency’s bereaved families. Findings include: Review of P11’s Plan of Care Summary, located in the electronic medical record (EMR) revealed P11 was admitted to hospice services on 02/07/25 with diagnoses including heart disease. A review of P11’s EMR located within the Bereavement tab revealed the Bereavement Coordinator (BC) Initial Bereavement Assessment was not conducted. The Comprehensive Nursing Assessment, dated 02/07/25, located within the Nursing section of the Assessments tab did not reveal any request to postpone or refuse the Bereavement Assessment, nor was a Bereavement Assessment completed by the visiting Registered Nurse (RN). The EMR did not contain a Communication Note documenting attempted contact by the BC or refusal of a visit for the Initial Bereavement Assessment. There was no evidence to explain the lack of completion. During an interview on 02/13/25 at 1:00 PM, the Administrator confirmed the record did not contain an initial bereavement assessment.”

“Based on interview and record review, the hospice agency failed to ensure the hospice staff provided pain and symptom management for two of 14 patients (Patient (P) P2 and P10) whose records were reviewed out of a total sample of 14. This deficient practice had the potential to adversely affect the quality of care, health, safety, and quality of life of the agency’s patients. Findings include: 1. A review of P2’s Nursing Comprehensive Assessment dated 02/15/24 and located within the Nursing section of the Assessments tab of the electronic medical record (EMR), revealed a failure to ensure initiation of interventions to manage pain for P2. The Nursing Comprehensive Assessment recorded pain rated by the patient at 7 of 10 (on a pain scale of 0 to 10) with a personal pain goal of three. The nursing narrative revealed that the nurse administered pain medication, but the nurse did not complete a reassessment of the patient’s pain level before the conclusion of the visit. There was no documented evidence of communication between the registered nurse and the physician regarding pain control. An interview with the Administrator on 02/13/25 at 1:00 PM, verified the nurse performing the assessment did not follow agency policy related to the assessment of medication effectiveness, reassessment of pain, and communication with the physician. 2. A review of P10’s Nursing Comprehensive Assessment, dated 09/13/24 and located within the Nursing section of the Assessments tab of the EMR, revealed a failure to ensure the initiation of interventions to manage pain for P10. The Nursing Comprehensive Assessment recorded pain rated by the patient at 5 out of 10, with no self-identified pain goal documented. The narrative section of this assessment recorded, “Pain is uncontrolled.” There was no documented evidence of communication between the registered nurse and the physician regarding pain control. These findings were discussed and reviewed in an interview with the Administrator on 02/13/25 at 1:00 PM. The Administrator verified the nurse performing the assessment did not follow agency policy related to completing an in-depth pain assessment and communication with the physician regarding symptom management.”

“Based on interview and record review, the hospice agency failed to ensure the hospice staff planned the scope and frequency of services necessary to meet the specific patient and family needs for two of 14 patients (Patient (P) P12 and P14). This deficient practice had the potential to adversely affect the quality of care, health, safety, and quality of life of all patients served by this agency by failing to provide the most appropriate level of service to their patients. Findings include: 1. A review of P12’s Plan of Care Summary with an effective date of 02/13/25 and located under the Plan of Care tab in the electronic medical record (EMR), revealed P12 was admitted to hospice services on 11/28/24 with diagnoses including atherosclerotic heart disease. Further review of the Plan of Care Summary revealed a lack of detailed Spiritual Care (SC) scope and visit frequency. On the Plan of Care Summary under the Treatment section, Spiritual Care was written as “SC initial assessment + 3 PRN and recertification . . .” On this same document, under the Frequency of Visit section, Spiritual Care was written as “SC: 1 per week + 3 PRN – SC: Initial Visit +3 PRN and recertification to provide . . .” It was unclear which scope and frequency would appropriately meet the patient’s needs, which should have been ordered by the physician, and conducted by the clinician. The Administrator was interviewed on 02/13/25 at 1:00 PM and explained that duplicate frequencies on the plan of care were a known problem, and all clinicians were being educated regarding this matter. 2. A review of P14’s Plan of Care Summary with an effective date of 02/13/25 and located under the Plan of Care tab in the EMR, revealed P14 was admitted to hospice services on 10/14/24 with diagnoses including atherosclerosis. Further review of the Plan of Care Summary revealed a lack of detailed Spiritual Care (SC) and Medical Social Worker (MSW) scope and visit frequency. On the Plan of Care Summary under the Treatment section, Spiritual Care was written as “SC: Initial assessment + 3 PRN and recertification . . .” and “MSW initial assessment + 3 PRN and recertification . . .” On this same document, under the Frequency of Visit section, SC and MSW were written as “1 per month + 3 PRN and recertification to provide . . .” It was unclear which scope and frequency would appropriately meet the patient’s needs, which should have been ordered by the physician, and conducted by the clinician. The Administrator was interviewed on 02/13/25 at 1:00 PM and explained that duplicate frequencies on the plan of care were a known problem, and all clinicians were being educated regarding this matter. These deficiencies were reviewed and confirmed by the Administrator.”

“Based on interview, record review, and policy review, the hospice agency failed to ensure the care plans contained measurable goals for 12 of 14 patients (Patient (P) P1, P2, P3, P4, P5, P7, P8, P9, P10, P11, P13, and P14). This deficient practice had the potential to adversely affect the quality of care, health, safety, and quality of life of all the agency’s patients. Findings include: A review of the agency’s policy titled, “The Plan of Care,” dated November 2020, revealed in the Procedure section number 12, “. . . The written care plan will contain but will not be limited to...” Item “W” of section 12 records, “. . . Measurable outcomes anticipated from implementing and coordinating the plan of care . . .” 1. A review of P1’s Interventions and Goals section located within the Plan of Care tab in the electronic medical record (EMR), reveals the following problems and associated goals with a lack of measurable outcomes. a. The Cardiovascular goal created on 10/22/24 recorded, Patient will have optimal cardiovascular status as evidenced by: b. The Gastrointestinal goal created on 10/22/24 recorded, Pt/pcg [primary caregiver] will verbalize/express understanding of medication/treatment orders and side effects. c. The Bereavement goal created on 10/22/24 recorded three goals, Be able to cope with changes, Bereaved will have knowledge of how to utilize bereavement services, and coping and acceptance of death by family/pcg. There was no further documented evidence of a measurable timeline or other measurement indicators of progress toward these goals. 2. A review of P2’s Interventions and Goals section located within the Plan of Care tab in the electronic medical record (EMR), revealed the following problems and associated goals with a lack of measurable outcomes. The Cardiovascular, Gastrointestinal, Infection/Immunological, and Neurological/Mental goals created on 02/15/24 all recorded, “Pt/pcg will verbalize/express understanding of medication/treatment orders and side effects.” There was no further documented evidence of a measurable timeline or other measurement indicators of progress toward these goals. 3. A review of P3’s Interventions and Goals section located within the Plan of Care tab in the electronic medical record (EMR), revealed the following problems and associated goals with a lack of measurable outcomes. a. The Gastrointestinal goal created on 11/01/24 recorded “Minimize signs and symptoms of GERD and Facilitate bowel elimination and comfort.” b. The Neurological/Mental goal created on 10/07/24 recorded, “Patient will have minimized episodes of anxiety and depression, Pt. will remain free from injury, and Pt/pcg will verbalize/express understanding of medication/treatment orders and side effects.” There was no further documented evidence of a measurable timeline or other measurement indicators of progress toward these goals. 4. A review of P4’s Interventions and Goals section located within the Plan of Care tab in the electronic medical record (EMR), revealed the following problems and associated goals with a lack of measurable outcomes. a. The Cardiovascular goal created on 05/13/24 recorded, “Patient will have optimal cardiovascular status as evidenced by:” with no further information of indications of optimal status. b. The Bereavement goal created on 10/22/24 recorded, “Be able to cope with changes and coping and acceptance of death by family/pcg.” c. The Musculoskeletal goal created on 05/13/24 recorded, “No injury when ambulating, increase strength/energy for functional activities, and Pt/pcg will verbalize/express understanding of medication/treatment orders and side effects.” There was no further documented evidence of a measurable timeline or other measurement indicators of progress toward these goals. 5. A review of P5’s Interventions and Goals section located within the Plan of Care tab in the electronic medical record (EMR), revealed the following problems and associated goals with a lack of measurable outcomes. a. The Psychosocial goal created on 10/21/24 recorded, “Familoy [sic] to complete final arrangements, DNR will be completed, and increase awareness of unnecessary ER visits.” b. The Neurological/Mental goal created on 11/21/24 recorded, “Patient will have minimized episodes of anxiety and depression.” c. The Respiratory goal created on 01/30/25 recorded, “Minimize episodes of shortness of breath.” There was no further documented evidence of a measurable timeline or other measurement indicators of progress toward these goals. 6. A review of P7’s Interventions and Goals section located within the Plan of Care tab in the electronic medical record (EMR), revealed the following problems and associated goals with a lack of measurable outcomes. a. The ADL [Activities of Daily Living] goal created on 11/01/24 recorded, “No depression noted, ADL needs are met, and Pt. will have a level of independence through assistance with personal care.” b. The Cardiovascular goal created on 11/01/24 recorded, “Patient will have optimal cardiovascular status as evidenced by:” c. The Environmental/Safety goal created on 11/01/24 recorded, “No injury during ambulation and going about activities of daily living.” There was no further documented evidence of a measurable timeline or other measurement indicators of progress toward these goals. 7. A review of P8’s Interventions and Goals section located within the Plan of Care tab in the electronic medical record (EMR) revealed the following problems and associated goals with a lack of measurable outcomes. a. The Musculoskeletal goal created on 10/10/24 recorded, “No injury when ambulating and Pt/pcg will verbalize/express understanding of medication/treatment orders and side effects.” b. The Neurological/Mental goal created on 10/11/24 recorded, “Patient will have minimized episodes of anxiety and depression, patient will remain free of injury and will minimize episodes of confusion and forgetfulness.” c. The Psychosocial goal created on 10/10/24 recorded, “Establish a trusting relationship with pt/family/pcg, facilitate resolution of issues, reduce emotional pain and suffering of anticipated loss, and increase awareness of unnecessary ER visits.” There was no further documented evidence of a measurable timeline or other measurement indicators of progress toward these goals. 8. A review of P9’s Interventions and Goals section located within the Plan of Care tab in the electronic medical record (EMR), revealed the following problems and associated goals with a lack of measurable outcomes. a. The Bereavement goal created on 05/10/24 recorded, “Be able to cope with changes and coping and acceptance of death by family/pcg.” b. The Cardiovascular goal created on 11/19/24 recorded, “Patient will have optimal cardiovascular status as evidenced by:” c. The Musculoskeletal goal created on 11/19/24 recorded, “No injury when ambulating.” There was no further documented evidence of a measurable timeline or other measurement indicators of progress toward these goals. 9. A review of P10’s Interventions and Goals section located within the Plan of Care tab in the electronic medical record (EMR) revealed the following problems and associated goals with a lack of measurable outcomes. a. The ADL [Activities of Daily Living] goal created on 09/13/24 recorded, “ No depression noted, ADL needs are met, and Pt. will have a level of independence through assistance with personal care.” b. The Gastrointestinal goal created on 09/13/24 recorded, “Minimize signs and symptoms of GERD and Facilitate bowel elimination and comfort.” c. The Genitourinary goal created on 09/13/24 recorded, “Minimize episodes of incontinence and patient will not develop any infection r/t foley catheter use.” There was no further documented evidence of a measurable timeline or other measurement indicators of progress toward these goals. 10. A review of P11’s Interventions and Goals section located within the Plan of Care tab in the electronic medical record (EMR), revealed the following problems and associated goals with a lack of measurable outcomes. a. The Musculoskeletal goal created on 02/09/25 recorded, “No injury when ambulating and Pt/pcg will verbalize/express understanding of medication/treatment orders and side effects.” b. The Neurological/Mental goal created on 02/09/25 recorded, “Patient will have minimized episodes of anxiety and depression, patient will remain free of injury and will minimize episodes of confusion and forgetfulness.” c. The Genitourinary goal created on 02/09/25 recorded, “Minimize episodes of incontinence and patient/family/pcg will verbalize having urinary elimination needs met at an acceptable level.” There was no further documented evidence of a measurable timeline or other measurement indicators of progress toward these goals. 11. A review of P14’s Interventions and Goals section located within the Plan of Care tab in the electronic medical record (EMR), revealed the following problems and associated goals with a lack of measurable outcomes. a. The ADL [Activities of Daily Living] goal created on 10/14/24 recorded, “ No depression noted, ADL needs are met, and Pt. will have a level of independence through assistance with personal care.” b. The Bereavement goal created on 10/14/24 recorded, “Bereaved will have knowledge of how to utilize bereavement services.” c. The Environmental/Safety goal created on 10/14/24 recorded, “No injury during ambulation and going about activities of daily living, no fall episode, and prevent pain and discomfort due to injury.” There was no further documented evidence of a measurable timeline or other measurement indicators of progress toward these goals. 12. Review of the Demographics in P13s EMR under the Demographics tab, indicated P13 was admitted for a start of care on 01/15/25 with a primary diagnosis of unspecified atherosclerosis. 13. Review of the Care Plans found in P13s EMR under the Care Plans tab indicated a Care Plan developed to address a potential for an alteration in cardiovascular status related to Nitroglycerin 0.5 milligrams (mg) and a Care Plan developed to address P13s constipation both had the goal of: “Pt/primary care giver will verbalize/express understanding of medication/treatment orders and side effects.” There were no parameters included in the goal for the purpose of measuring P13s progress. An interview was conducted with the agency Administrator on 02/13/25 at 1:00 PM. The Administrator verbalized knowledge of the requirement for measurable goals, further stating, “I teach them to update the care plans every two weeks for IDG (Interdisciplinary Group meetings). They move the target date up to the next scheduled IDG date.” The Administrator voiced that the presence of a target date does not make a goal or outcome measurable or provide individualization of the plan of care, and the staff would be educated.”

“Based on interview and record review, the hospice agency failed to ensure the services provided by the hospice staff followed the care plan for two of 14 patients (Patient (P) P6 and P8) whose records were reviewed out of a total sample of 14. This deficient practice had the potential to adversely affect the quality of care, health, safety, and quality of life of the agency’s patients. Findings include: A review of P6’s Plan of Care Summary dated 02/10/25, located within the Plan of Care tab in the electronic medical record (EMR), revealed P6 was admitted to hospice services on 08/27/24 with diagnoses including heart failure. Further review of the Plan of Care Summary revealed documentation the durable medical equipment needed by the patient was a cane and walker. During the home visit on 02/10/25 at 11:00 AM, the patient and Registered Nurse (RN1) verified this equipment was not utilized and had not been provided to the patient. A review of P8’s Plan of Care Summary, dated 02/12/25 and located under the Plan of Care tab of the EMR, revealed P8 was admitted to hospice services on 10/10/24 with diagnoses including schizophrenia. Further review of the Plan of Care Summary, under the Psychosocial section, recorded the frequency for the Medical Social Worker (MSW) ordered on 10/10/24 as “MSW: initial assessment +3 PRN and recertification . . .” There is no documented evidence the recertification visit was completed, as the Psychosocial Assessment for the recertification visit dated 01/08/25, located within the Assessments tab, was incomplete, with only the date and time filled in. During an interview on 02/13/25 at 1:00 PM, the Administrator confirmed there was no documentation that the recertification was completed.”

“Based on interview, record review, and policy review, the hospice agency failed to ensure the hospice staff followed agency policy and accepted standards of practice for infection control for one of 14 patients (Patient (P) P6) whose records were reviewed out of a total sample of 14. This deficient practice had the potential to adversely affect the health, safety, and quality of life of the agency’s patients. Findings include: Review of the agency’s policy titled, “Risk Management: Infection and Safety Control,” revised November 2020, indicates the procedure for decontaminating hands with an alcohol-based hand rub: section 3A recorded, “. . . before having direct contact with the patient. . . “ and section 3G recorded, “. . . after removing gloves . . .” Review of P6’s Plan of Care Summary, located in the electronic medical record (EMR), revealed P6 was admitted to hospice services on 08/27/24 with diagnoses including heart failure. During the home visit with P6 on 2/11/25 at 11:00 AM, Registered Nurse (RN1) performed hand hygiene, donned gloves, and then began performing a nursing assessment. RN1 then doffed gloves, and without performing hand hygiene, donned gloves and continued the assessment. Review of RN1’s employee file revealed RN1 had completed the Hand Hygiene Competency Checklist, undated, signed 01/03/25, a Handwashing Check-off, undated, signed by the employee 01/04/24, and an Infection Control Acknowledgement of review of the exposure control plan, undated, signed on 03/03/24. During an interview on 02/13/25 at 1:00 PM, the Administrator verified RN1 had received training on hand hygiene.”

“Based on record review, policy review, and interview, the Hospice failed to ensure 6 of 11 Hospice Aides (HA1, HA2, HA5, HA6, HA7, HA8) received the required 12 hours of continuing education in a 12-month period. Failure to provide training to Hospice Aides has the potential to affect the care provided to 15 patients receiving Hospice services. Findings include: Review of the online training records for the eleven Hospice Aides (HA) indicated all HAs received online training equaling 48.03 hours on hire. The Hospice in-service training records for all eleven HAs indicated that during the years following their initial on hire training, had no documented evidence of any further training completed on the agencies online training program- Relias, instead, each HA signed an attestation indicating completion of the training listed on the attestation as follows: Emergency Preparedness AssessmentHome Safety AssessmentCorporate Compliance AssessmentElder Abuse AssessmentAssessment Sexual Harassment at Work SafetyElectrical Safety and Home CareBereavement ProgramVolunteer ProgramCOVID-19 Precautioninfection control and Pulmonary TuberculosisMedical Device Reporting Regulations. (MDR)Hazardous ChemicalsPathogens and infection ControlSafety WorkplaceBlood borne and Pathogens ManagementProfessional BoundariesIncident and Fall PrecautionPain ManagementFalse Claim Act Education Policy and Corporate Compliance Policy Acknowledgement There was no documentation on the attestations to indicate the HAs had received 12 hours of training during the years following their initial on-hire Relias training. 1. Review of the Employee Personnel File for HA1 indicated that HA1 had a date of hire of 01/09/23 and completed the Relias online training totaling 48.03 hours. Review of HA1s training record for 2024 and 2025 indicated HA1 signed an attestation dated 01/09/24 and an additional attestation dated 01/03/25 to indicate HA1 had received the required 12 hours of training in each 12-month period. The attestation form included a list of training subjects. There was no documentation on the attestations that indicated the list of training subjects totaled the 12 hours per 12-month period required for HAs. 2. Review of the Employee Personnel File for HA2 indicated that HA2 had a date of hire of 04/10/23 and completed the Relias online training totaling 48.03 hours. Review of HA2s training record for 2024 and 2025 indicated HA2 signed an attestation dated 01/02/24 and an additional attestation dated 01/04/25 to indicate HA2 had received the required 12 hours of training in each 12-month period. The attestation form included a list of training subjects. There was no documentation on the attestations that indicated the list of training subjects totaled the 12 hours per 12-month period required for HAs. 3. Review of the Employee Personnel File for HA5 indicated that HA5 had a date of hire of 10/02/23 and completed the Relias online training totaling 48.03 hours. Review of HA5s training record for 2024 and 2025 indicated HA5 signed an attestation dated 01/02/24 and an additional attestation dated 01/04/25 to indicate HA5 had received the required 12 hours of training in each 12-month period. The attestation form included a list of training subjects. There was no documentation on the attestations that indicated the list of training subjects totaled the 12 hours per 12-month period required for HAs. 4. Review of the Employee Personnel File for HA6 indicated that HA6 had a date of hire of 08/28/23 and completed the Relias online training totaling 48.03 hours. Review of HA6s training record for 2024 and 2025 indicated HA6 signed an attestation dated 01/03/24 and an additional attestation dated 01/04/25 to indicate HA6 had received the required 12 hours of training in each 12-month period. The attestation form included a list of training subjects. There was no documentation on the attestations that indicated the list of training subjects totaled the 12 hours per 12-month period required for HAs. 5. Review of the Employee Personnel File for HA7 indicated that HA7 had a date of hire of 06/19/23 and completed the Relias online training totaling 48.03 hours. Review of HA7s training record for 2024 and 2025 indicated HA7 signed an attestation dated 01/04/24 and an additional attestation dated 01/03/25 to indicate HA7 had received the required 12 hours of training in each 12-month period. The attestation form included a list of training subjects. There was no documentation on the attestations that indicated the list of training subjects totaled the 12 hours per 12-month period required for HAs. 6. Review of the Employee Personnel File for HA8 indicated that HA8 had a date of hire of 06/08/23 and completed the Relias online training totaling 48.03 hours. Review of HA8s training record for 2024 and 2025 indicated HA8 signed an attestation dated 01/04/24 and an additional attestation dated 01/06/25 to indicate HA8 had received the required 12 hours of training in each 12-month period. The attestation form included a list of training subjects. There was no documentation on the attestations that indicated the list of training subjects totaled the 12 hours per 12-month period required for HAs. Review of the facility policy No. 1-029.6 dated 11/2020, indicated the organization will offer 12 hours of in-service training annually. During an interview with the Administer on 02/13/25 at 10:00 AM, the Administrator said HAs receive the 48.03 Relias hours on hire and after that, during each year, training is not done on Relias, but instead the HAs sign an attestation they have reviewed specific trainings, and a certificate is given after the attestation is signed. The Administrator agreed that there was no documentation to indicate the HAs were meeting the 12 hours of training per 12-month period required by regulation.”

“Based on interview, record review, and policy review, the hospice agency failed to ensure the hospice aide provided services included in the care plan for one of 14 patients (Patient (P) P10) whose records were reviewed out of a total sample of 14. This deficient practice had the potential to adversely affect the safety and quality of life of the agency’s patients. Findings include: Review of the agency’s policy titled, “Hospice Aide Services,” dated November 2020, revealed, “. . . Hospice aide services . . . will be assigned and supervised by a hospice nurse . . . Hospice aide assignments, plan of care, and interventions will be document and included in the patient’s clinical record . . .” Review of P10’s Plan of Care Summary, located in the electronic medical record (EMR), revealed P10 was admitted to hospice services on 09/13/24 with diagnoses including atherosclerotic heart disease. A review of P10’s HA (Hospice Aide) Visit Note, located within the Aide section of the EMR, showed the visit notes dated 01/24/25 and 01/31/25. Both documented instructions to obtain vital signs every visit. No evidence was contained in these visit notes that vital signs were obtained as instructed. There was no documentation of patient or caregiver refusal or report to the case manager of failure to complete vital signs. An interview with the Administrator on 02/13/25 at 1:00 PM revealed the aides do not always take vital signs, and it depends on the nurse. The Administrator stated the aide should follow the instructions given and let the nurse know if they can’t.”

“Based on documentation review and interview, the facility failed to demonstrate viable and ongoing efforts of actively attempting to recruit volunteers. This had the potential to cause 16 of 16 patients to have unmet needs. Findings include: Review of the Volunteer’s binder indicated the method used for recruitment was a flyer. There was no evidence of any other methods being used. Review of the Volunteer Activity schedules dated for 2023, 2024, 2025, and 2026 indicated all the schedules and plans were the same, containing the same recruitment plans every year as follows: January- ACHC Volunteer Program Training and Inservice for Roles and Responsibilities. Flyers went out and were posted at church, grocery store and Restaurant. February- Meeting with Clinical staff regarding recruitment plan (volunteer requirement) March- Flyers went out and posted at church, grocery store, laundromat, and restaurant. April- Meeting follow up regarding recruitment plan. May- Training and Services Hospice MD volunteer documentation June- Training and Inservice Hospice MD to get report. July- Flyers went out and posted at the church. August- Training and Inservice on different types of volunteers September- “;Flyers went out posted at restaurant and laundromat.” October- “;Training and In-services Facility November- “;Flyers went out and posted at grocery store.” December- “;Re-evaluation of recruitment plan and training and in-service” During an interview with the Volunteer Coordinator (VC) (also the Administrator) on 01/13/25 at 12:35 PM, the VC said the facility has not recruited at local schools or colleges because students do not want to do things like that. The VC said they had not approached any other local groups as of this date. The VC agreed that the plan needed to be revised, and more active recruitment needed to take place. The VC said that recruitment was not good right now, most volunteering takes place under the administrative area, not care of patients. Review of the minutes of the Governing Body, dated 01/05/25 indicated the Governing body met to discuss plans for Volunteer recruitment and retention. Plans for volunteer recruitment related to the improvement or marketing for new volunteers in 2025 and 2026 were to be revised because previous plans documented are the same.”

“Based on interview and contract review, the hospice agency failed to ensure the hospice specified the physician who assumes the Medical Director’s responsibilities and obligations in one of two contracts. This deficient practice had the potential to adversely affect the continuity and timeliness of care received by the agency’s patients. Findings include: Based on interview and contract review, the hospice agency failed to ensure that the hospice specified the physician who assumes the Medical Director’s responsibilities and obligations in one of two contracts. This deficient practice had the potential to adversely affect the continuity and timeliness of care received by the agency’s patients. Findings include: A review of the “Professional Services Agreement Medical Director,” revised November 2020 and signed by the Associate Medical Director on 12/12/24, failed to delineate the “Alternate” or “Designee” role, duties, and responsibilities. The contract contains only verbiage related to the direct role of “Medical Director.” There was no evidence of delegation, orientation, or understanding of this clinician assuming the “Alternate” or “Designee” role. During an interview on 02/13/25 at 1:00 PM the Administrator confirmed this stating, “That is the only contract we have.””

“Based on interview and contract review, the hospice agency failed to ensure the hospice specified the physician who assumes the Medical Director’s responsibilities and obligations in one of two contracts. This deficient practice had the potential to adversely affect the continuity and timeliness of care received by the agency’s patients. Findings include: A review of the Professional Services Agreement- Medical Director, revised November 2020 and signed by the Associate Medical Director on 12/12/24, failed to delineate the alternate or designee role, duties, and responsibilities. The contract contained verbiage related to the direct role of the Medical Director. There was no evidence of delegation, orientation, or understanding of this clinician assuming the alternate or designee role. During an interview on 02/13/25 at 1:00 PM, the Administrator confirmed this stating, “that is the only contract we have.””

“Based on interview, record review, and policy review, the hospice agency failed to ensure the only licensed and professional staff member accepted and transcribed verbal physician orders for 6 of 14 patients (Patient (P) P5, P8, P9, P10, P12, and P14) whose records were reviewed out of a total sample of 14. This deficient practice had the potential to cause adverse effects on the quality of care, quality of life, health, and safety of the agency’s patients. Findings include: Review of the agency’s policy titled, “Verification of Physician Orders,” revised November 2020, revealed, “. . . To ensure that accurate physician . . . orders are obtained in accordance with applicable law and regulation . . . Orders will be obtained from a licensed physician (or other authorized independent practitioner) for care and services to be provided to hospice patients . . . Verbal orders will be taken and documented only by professional, licensed hospice personnel . . .” 1. Review of P5’s Plan of Care Summary, located in the electronic medical record (EMR), revealed P5 was admitted to hospice services on 10/17/24 with diagnoses including other disorders of the brain. A review of P5’s electronic medical record (EMR) revealed a Physicians Order dated 02/11/25 and located within the Physician tab, recording, “. . . Patient was discharged from New Century Hospice, Inc. due to status improved. MD notified.” This order was indicated to be a phone order/read back with a digital signature attached belonging to an administrative employee who was not a licensed clinician. 2. Review of P8’s Plan of Care Summary, located in the EMR, revealed P8 was admitted to hospice services on 10/10/24 with diagnoses including schizophrenia. A review of P8’s EMR reveals inappropriately completed Physician Orders” located within the Physician tab: a. Physician Order dated 12/20/24 recorded, “Patient declined SC [Spiritual Care]. MD notified. We will offer SC service next month.” This order was indicated as, Phone order/read back by...(ADMIN). The person signing as receiving this order was not a licensed clinician and was employed as an administrative employee of the agency. b. Physician Order dated 12/12/24 recorded, “Patient declined MSW [Medical Social Worker]. MD notified. We will offer MSW service next month.” This order was indicated as, Phone order/read back by...(ADMIN). The person signing as receiving this order was not a licensed clinician and was employed as an administrative employee of the agency. c. Physician Order dated 12/13/24 recorded, “Patient declined MSW [Medical Social Worker]. MD notified. We will offer MSW service next month.” This order was indicated as, Phone order/read back by...(ADMIN). The person signing as receiving this order was not a licensed clinician and was employed as an administrative employee of the agency. 3. Review of P9’s Plan of Care Summary, located in the EMR, revealed P9 was admitted to hospice services on 05/10/21 with diagnoses including atherosclerotic heart disease. A review of P9’s EMR reveals inappropriately completed Physician Orders located within the Physician tab: a. Physician Order dated 11/25/24 recorded, “Patient declined SC [Spiritual Care]. MD notified. Will offer SC services next month.” This order was indicated as, Phone order/read back by...(ADMIN). The person signing as receiving this order was not a licensed clinician and was employed as an administrative employee of the agency. b. Physician Order dated 01/10/25 recorded, “MSW [Medical Social Worker]. Patient refused MSW services. MD notified. Will offer MSW services next month.” This order was indicated as, Phone order/read back by...(ADMIN). The person signing as receiving this order was not a licensed clinician and was employed as an administrative employee of the agency. c. Physician Order dated 01/10/25 recorded, “SC [Spiritual Care]. Patient refused SC services. MD notified. Will offer SC services next month.” This order was indicated as, Phone order/read back by...(ADMIN). The person signing as receiving this order was not a licensed clinician and was employed as an administrative employee of the agency. 4. Review of P10’s Plan of Care Summary, located in the EMR, revealed P10 was admitted to hospice services on 09/13/24 with diagnoses including atherosclerotic heart disease. A review of P10’s EMR revealed inappropriately completed Physician Orders located within the Physician tab: a. Physician Order dated 09/18/24 recorded, “Patient declined Volunteer. MD notified. We will offer Volunteer program next month.” This order was indicated as, “Phone order/read back by...(ADMIN).” The person signing as receiving this order was not a licensed clinician and was employed as an administrative employee of the agency. b. “Physician Order” dated 10/18/24 recorded, “Patient declined SC [Spiritual Care]. MD notified. Will offer SC services next month.” This order was indicated as, Phone order/read back by...(ADMIN). The person signing as receiving this order was not a licensed clinician and was employed as an administrative employee of the agency. c. Physician Order dated 11/22/24 recorded, Patient declined MSW [Medical Social Worker]. MD notified. We will offer MSW service next month.” This order was indicated as, Phone order/read back by...(ADMIN). The person signing as receiving this order was not a licensed clinician and was employed as an administrative employee of the agency. 5. Review of P12’s Plan of Care Summary, located in the EMR, revealed P12 was admitted to hospice services on 11/28/24 with diagnoses including atherosclerotic heart disease. A review of P12’s EMR revealed inappropriately completed Physician Orders located within the Physician tab: a. Physician Order dated 01/07/25 records, “Patient refused visit. MD notified. Will offer MSW [Medical Social Worker] service next month.” This order was indicated as, Phone order/read back by...(ADMIN). The person signing as receiving this order was not a licensed clinician and was employed as an administrative employee of the agency. b. Physician Order dated 12/03/24 recorded, “Patient declined Volunteer. MD notified. We will offer next visit.” This order was indicated as, Phone order/read back by...(ADMIN). The person signing as receiving this order was not a licensed clinician and was employed as an administrative employee of the agency. 6. Review of P14’s Plan of Care Summary, located in the EMR, revealed P14 was admitted to hospice services on 10/14/24 with diagnoses including atherosclerosis and angina pectoris. A review of P14’s EMR revealed inappropriately completed Physician Orders located within the Physician tab: a. Physician Order” dated 12/21/24 records, “Patient declined SC [Spiritual Care]. MD notified. We will offer SC services next month.” This order was indicated as, “Phone order/read back by...(ADMIN).” The person signing as receiving this order was not a licensed clinician and was employed as an administrative employee of the agency. b. “Physician Order dated 01/14/25 records, “MSW [Medical Social Worker]. Patient refused MSW services. MD notified. Will offer MSW services next month.” This order was indicated as, Phone order/read back by...(ADMIN). The person signing as receiving this order was not a licensed clinician and was employed as an administrative employee of the agency. During an interview with the Administrator on 02/13/25 at 1:00 PM, the above findings were discussed. The Administrator acknowledged the administrative employee was not a licensed clinician. The Administrator further stated that the employee only creates the Physician Orders and the Medical Director signs them. However, when pointing out the Physician Orders all indicate Phone Order/Read back by the unlicensed employee, there was no further explanation.”

“Based on interview, record review, and policy review, the hospice agency failed to ensure the patient received adequate discharge planning and the patient’s physician received the necessary documents to ensure continuity of care for 2 of 14 patients (Patient (P) P5 and P6) whose records were reviewed out of a total sample of 14. This deficient practice had the potential to adversely affect the quality of care, health, safety, and quality of life of the agency’s patients. Findings include: A review of the policy revised in November 2020, named “ Discharge from Hospice Program,” indicates nonadherence to agency policy related to the discharge of P5 and P6. -Section one under Discharge Criteria stated, “the Medical Director and/or attending physician will determine if the patient is not hospice-appropriate...” -Under the Procedure” section, number one states, “ the hospice interdisciplinary group will develop a discharge plan.” -Under the Procedure section, number two states, “the case manager will ensure that necessary paperwork is completed at the time of discharge. This will include... and a written physician order to discharge”. 1. Review of P5’s electronic medical record (EMR) revealed P5 was admitted to hospice services on 10/17/24 with diagnoses including other disorders of the brain. A home visit was made to P5 on 02/11/25 at 12:30 PM. During this visit, the patient and spouse discussed with the Medical Social Worker (MSW) the goals of care and interest in pursuing aggressive treatment. The MSW was heard to educate the patient on the choice to revoke hospice services. The patient and spouse also verbalized they didn’t exactly know how they ended up on hospice. The patient’s spouse further states they never were told the patient was dying. The MSW informed the patient and spouse during the visit, the Registered Nurse had been notified of the desire to discuss the revocation of hospice services. Upon arrival at the agency, a record review revealed the patient had been discharged from the agency on the same date, 02/11/25. The Discharge Summary, dated 02/11/25 and located in the EMR within the Discharge tab, documented, “Patient was discharged from hospice due to status improved. MD notified.” There was no evidence of discharge planning as the Discharge Plan form within the Discharge tab of the EMR was blank. There was no evidence of interdisciplinary collaboration or formulation of a discharge plan. There was no order or input from the Medical Director regarding the need for discharge planning based on clinical judgment and lack of decline. There was a Physicians Order dated 02/11/25 located within the Physician tab of the EMR, which recorded, “. . . Patient was discharged from hospice due to status improved. MD notified . . .” This order was indicated to be a phone order/read back with a digital signature attached belonging to an administrative employee who was not a licensed clinician. In an interview on 02/11/25 at 1:00 PM, the Administrator verified these findings. The Administrator further stated, the discharge was my action, we will investigate and can admit again if they need it. The Administrator verbally verified the patient did not choose to revoke services but was discharged. 2. Review of P6’s EMR revealed P6 was admitted to hospice services on 08/28/24 with diagnoses including heart failure. During the home visit with P6 on 02/11/25 at 11:00 AM, the interview with the patient revealed no questionable statements or concerns regarding hospice care mentioned by the patient. The patient did not mention revocation of the hospice benefit, nor did the Registered Nurse (RN1) mention any pending discharge due to status improvement or discharge planning. Upon returning to the agency, the Administrator stated the patient was discharged following the home visit, explaining this was due to the report received from Registered Nurse (RN1) present during the home visit that “the patient did not know what was going on, why was on hospice and said something about money being involved for referrals.” The patient did not verbalize any of this to the surveyor. The Administrator further acknowledged no discharge planning was provided, as evidenced by the Discharge Plan form located within the Discharge tab of the EMR, which was blank. The Administrator stated the patient was notified of discharge by telephone call. The Physician Order, dated 02/11/25 within the Physician tab of the EMR, recorded the patient was discharged due to lack of decline and MD notified. There was no documented order or input from the Medical Director regarding the need for discharge planning based on clinical judgment and lack of decline. The Visit Note RN, dated 02/11/25 and located within the Visit Notes tab in the EMR, indicated a routine visit performed. There was no mention of discharge or discharge planning. The Discharge Summary, located within the Discharge tab, did not indicate, and the administrator verified verbally that the patient’s physician was not sent a copy of the discharge summary, a medication list, a plan of care, or any report.”