Hospice Buffalo Inc.

“Based on review of clinical records and staff interview, one (1) of twenty-seven (27) patients (Patient #’s: 14), lack a comprehensive assessment performed by the hospice interdisciplinary group within five (5) days after the election of hospice care. Failure of the IDG members to participate in completing the comprehensive assessment has the potential to place the patient/family at risk for the development of incomplete and/or inaccurate Plans of Care.The agency failed to ensure a comprehensive assessment conducted by the interdisciplinary group within five days as evidenced by the following: Patient #14 – This 78-year-old patient with a terminal diagnosis of end-stage high-grade serous carcinoma of the ovary involving pleura with a malignant pleural effusion and abdominal carcinomas was admitted to the hospice on 4/18/2025.A. Review of the Hospice Certification and Plan of Care from 4/18/2025 to 7/16/2025 revealed the following order: Chaplain (CH) effective 4/20/2025 1 week 1.Review of the Chaplain Hospice Add-on Evaluation note dated 04/29/2025 revealed the first Chaplain visit was completed on 04/29/2025, eight (8) days after the start of care.During interview on 05/15/2025 at 9:10 AM, the Chief of Clinical Operations stated that the Chaplain did not see the patient within five (5) days of the start of care. A voicemail was left by the Chaplain on 4/21/2025, however, no further attempt to initiate services was completed until the following week. B. Review of the clinical record lacked documented evidence that the interdisciplinary group collaborated on an initial comprehensive plan of care within five (5) days of the start of care. During interview on 5/14/2025 at 11:32 AM, the Chief of Clinical Operations confirmed that there was no initial interdisciplinary group plan of care collaboration note in the patient’s record and there should have been.”

“Based on review of clinical records and interviews with agency staff, the hospice failed to ensure in three (3) of twenty- seven (27) clinical records (Patient #’s: 3, 19, and 20), the content of the comprehensive assessment is of sufficient scope to identify all the patient’s needs to promote the patient’s well-being and comfort throughout the dying process. Failure to ensure assessments are comprehensive has the potential for unmet patient needs and the likelihood of patient harm. The agency failed to ensure the content of the comprehensive assessment is of sufficient scope to identify all the patient’s needs to promote the patient’s well-being and comfort throughout the dying process as evidenced by: Patient #3 – This 92-year-old patient with a terminal diagnosis of unspecified diastolic (congestive) heart failure was admitted to the hospice on 04/19/2025. Review of the clinical record from 04/19/2025 to 05/05/2025 lacked documented evidence the patient’s immunization status was assessed. During an interview on 05/14/2025 at 12:38 PM, the Vice President of Quality Improvement stated no, there is no documentation to show that the patient’s immunization status was assessed and that there should be a note in the clinical record to clarify the patient’s immunization status. Patient #19- This 64-year-old patient with a terminal diagnosis of senile degeneration of the brain, not elsewhere classified was admitted to the hospice on 04/18/2025. Review of the Registered Nurse Start of Care Visit Note dated 10/11/2024 lacks documented evidence the Registered Nurse assessed the patient’s immunization status. During interview on 05/14/2025 at 01:24 PM, the Vice President of Quality Improvement stated that there are no vaccinations documented in this patient’s record. Patient #20- This 83-year-old patient with a terminal diagnosis of cerebral vascular disease, unspecified was admitted to the hospice on 04/15/2025. Review of the agency’s policy entitled “Alterations in Skin Integrity - Assessment, Early Intervention and General Treatment” dated 04/20/2010 revealed the following:1. “Assessment of skin integrity; A. All patients should have an integumentary assessment completed at the time of admission and with each comprehensive assessment.B. The documentation of altered skin integrity will occur at the time of detection and will be completed weekly thereafter for all skin integrity issues.ii. Documentation of malignant wounds, sutured surgical incisions, skin tears, rashes, fistulas, cancerous tumors and all other wounds or skin issues is to be done in the “integumentary” section of the RN assessment.”iii. The wound care documentation will include the wound care provided, description of the wound, and the patient response to care.” Review of the Registered Nurse Admission Visit Note dated 04/15/2025 revealed the Registered Nurse documented the patient has a skin tear to the right wrist. The visit note lacks documented evidence of an assessment of the skin tear. The hospice failed to ensure the content of the comprehensive assessment is of sufficient scope to identify all the patient’s needs to promote the patient’s well-being and comfort throughout the dying process. During interview on 05/14/2025 at 10:07 AM, the Chief of Clinical Operations stated that the Registered Nurse did not clearly assess the area, no wound care orders were documented, so the wound was likely left open to air, but the Chief of Clinical Operations could not confirm that. Additionally, the Chief of Clinical Operations stated that there should be some documentation on the Plan of Care for wound care and monitoring.”

“Based on review of clinical records, agency policy and procedure, and interviews with staff, for one (1) of twenty-seven (27) clinical records (Patient #16), the hospice failed to ensure that nursing staff complete an accurate and comprehensive drug profile review. Failure to complete accurate and comprehensive drug reviews has the potential for patients to experience drug interactions/side effects, and/or the Interdisciplinary Group to act on inaccurate information. Review of the agency policy and procedure entitled “Drug Profile Review, Management of Drugs and Biologicals, & Monitoring for Optimal Pharmaceutical Outcomes dated 04/20/2010 revealed the following:”a. The admission nurse will review all prescription medications, OTC (over the counter) medications, vitamin/mineral supplements, herbal/alternative remedies, and illicit drugs that could affect drug therapy.i. Medication information will be obtained from all sources possible including but limited to mediation bottles, devices, or vials, discharge instructions/ orders, physician office notes, and patient/family reports of administration use.ii. The patient’s physician will be contacted to review all pre-admission medications and obtain admission medication orders.1. The admission nurse will identify pre-admission medications not continued or changed, and new medication orders obtained.iii. If the patient is taking medications prescribed by more than one physician, orders will be obtained at time of admission from the patient’s primary physician to verify all medications.iv. The nurse will collaborate with the attending/ordering physician and the hospice medical director/hospice physician or nurse practitioner/hospice pharmacist as appropriate, to correlate current therapy with each patient problem/disease. The following concepts will be incorporated; therapeutic objectives related to palliation and management of the terminal illness and related conditions, selection of the best therapy inclusive of the least obtrusive and most cost effective, and consideration of the patient variables that would affect medication pharmacokinetic and pharmacodynamics.v. The physician’s admission orders will be entered into the patient’s record.” Patient #16 – This 99-year-old patient with a terminal diagnosis of unspecified diastolic (congestive) heart failure was admitted to the hospice on 04/18/2025. A. Review of the Encounter for Annual Wellness Visit dated 04/14/2025 revealed the following medication order:- Brinzolamide (Azopt) 1% ophthalmic suspension – administer 1 drop into both eyes in the morning and 1 drop before bedtime. Review of the Hospice Certification and Plan of Care from 04/18/2025 to 07/16/2025 revealed the following order:- Brinzolamide 1% eye drops, suspension – 1 drop daily, reason: glaucoma, instructions: right eye. Review of RN (Registered Nurse) Hospice Admission Visit dated 04/18/2025 revealed the Registered Nurse documented the following:Medication ReconciliationPre-admission medication list reviewed with hospice medical director, patient, and primary caregiver.Indicate information reviewed: Physician Office EMR (Electronic Medical Record) MED (Medication) List, pill bottles, scripts, and OTC (over the counter) medications in the home.Pre-admission medications discontinued: artificial tears, vitamin D2, furosemide, and lidocaine solution.Pre-admission medications changed: Tylenol, tramadol, iron, and metoprolol succ (succinate) ER (extended Release).New medications added to the plan of care: Colace, Dulcolax tablet, comfort pack, lidocaine patch, Synthroid, and Claritin.Status of Medication Reconciliation: medication list, PRN (as needed) log and pill bottles reviewed and reconcile, no follow up needed.There is a lack documented evidence that the Registered Nurse discussed the discrepancy with the physician.Review of the IDG Summary Report dated 04/22/2025 lacked documented evidence the medication discrepancy was discussed during the meeting. During an interview on 05/14/2025 at 03:38 PM, the Admissions Registered Nurse stated that the Admissions Registered Nurse does not recall if the patient was to be using the brinzolamide 1% eye drops in the right eye or in both eyes. B. Review of the Encounter for Annual Wellness Visit dated 04/14/12025 revealed the following medication order:- dorzolamide (Trusopt) 2% ophthalmic solution – administer into affected eye(s). Review of the Hospice Certification and Plan of Care from 04/18/2025 to 07/16/2025 lacked an order for the medication. Review of RN (Registered Nurse) Hospice Admission Visit dated 04/18/2025 revealed the Registered Nurse documented the following:Medication ReconciliationPre-admission medication list reviewed with hospice medical director, patient, and primary caregiver.Indicate information reviewed: Physician Office EMR (Electronic Medical Record) MED (Medication) List, pill bottles, scripts, and OTC (over the counter) medications in the home.Pre-admission medications discontinued: artificial tears, vitamin D2, furosemide, and lidocaine solution.Pre-admission medications changed: Tylenol, tramadol, iron, and metoprolol succ (succinate) ER (extended Release).New medications added to the plan of care: Colace, Dulcolax tablet, comfort pack, lidocaine patch, Synthroid, and Claritin.Status of Medication Reconciliation: medication list, PRN (as needed) log and pill bottles reviewed and reconcile, no follow up needed.There is a lack of documented evidence that the Registered Nurse discussed the discrepancy with the physician. Review of the Initial IDT (Interdisciplinary Team) POC (Plan of Care) Collaboration dated 04/22/2025 lacked documented evidence the medication discrepancy was discussed during the meeting. During an interview on 05/14/2025 at 03:39 PM, the Admissions Registered Nurse stated that the Admissions Registered Nurse does not recall if the patient was to be using the dorzolamide 2% ophthalmic solution.”

“Based on review of clinical records and interviews with staff for three (3) of twenty- seven (27) clinical records (Patient #s: 1, 4, and 9), the hospice failed to provide services according to the Plan of Care. Failure to provide services in accordance with the Plan of Care has the potential for unmet patient needs. The hospice failed to provide services according to the Plan of Care as evidenced by the following: Patient #1 – This 73-year-old patient with the terminal diagnosis of chronic obstructive pulmonary disease, unspecified was admitted to the hospice on 04/04/2025.Review of the Plan of Care Update Order dated 04/11/2025 revealed an order for a Home Health Aide (HHA) effective 04/13/2025 at the following frequency: two (2) visits per week for eleven (11) weeks, and one (1) time a week for one (1) week.Review of the clinical record for the week of 04/13/2025 through 04/19/2025 revealed the HHA provided services one day during that week, on 04/17/2025. Review of the clinical record lacks documented evidence that the patient and/or physician requested a change in the Home Health Aide visit frequency.During interview on 05/15/2025 at 09:03 AM, the Chief of Clinical Operations stated that visits are scheduled Monday through Friday and the visit was done on Thursday and another visit was not scheduled for that week.During interview on 05/15/2025 at 09:04 AM, the Vice President of Quality Improvement stated that the nurse obtains the order frequency and then the scheduler puts in the frequency to populate on the schedule. Additionally, the scheduler then contacts the family to schedule the visits and would remove any frequencies that cannot be met and should have put in a note if any are missed. Review of the Massage Therapy Hospice Add-on Evaluation visit dated 4/25/2025 revealed the Licensed Massage Therapist documented the following: “Frequency is set at one (1) to four (4) times per month and as needed to address discomfort and provide ongoing support.”Review of the Hospice Add-On order dated 4/25/2025 revealed the following: “Massage Therapy Effective 4/20/2025 3 every 2 weeks for 2 weeks, 1 week 10.”Review of the clinical record for the weeks of 4/20/2025 through 05/3/2025 revealed two (2) Licensed Massage Therapy visits occurred on 04/25/2025 and 05/2/2025.Review of the clinical record lacked documented evidence that the Massage Therapy frequency was implemented as ordered by the physician.During interview on 5/14/2025 at 11:25 AM the Chief of Clinical Operations stated that a frequency order should not be a range as documented in the Massage Therapist’s note. The agency was going to look at their visit documentation calendar to identify if more visits were made.During interview on 5/15/2025 at 8:55 AM, the Vice President of Quality Improvement stated that there were no further Massage Therapy appointments and that the order should have been updated to reflect the following frequency “1 week 2, 12 as needed for change of condition.” Patient #4- This 87-year-old patient with the terminal diagnosis of chronic obstructive pulmonary disease, unspecified was admitted to the hospice on 02/03/2025. Review of the Hospice Certification and Plan of Care from 02/03/2025 revealed the following order: Frequency/ Duration of Visits: Skilled Nurse- three (3) visits per week for one (1) week, two (2) visits per week for three (3) weeks, one (1) visit per week for one (1) week, and twenty- six (26) As Needed Visits for Changes in Condition. Review of the clinical record for the week of 02/23/2025 through 03/01/2025 revealed only one Skilled Nurse visit occurred on 02/26/2025, instead of the two visits ordered. Review of the clinical record lacks documented evidence that the patient and/ or physician requested a change in the Skilled Nurse visit frequency. During an interview on 05/15/2025 at 09:28 AM, the Vice President of Quality Improvements stated that the agency was not able to find any missed visit notifications for the week of 0/23/2025 through 03/01/2025.”

“Based on a review of clinical records and interview with agency staff for one (1) of twenty-seven (27) patients (Patient #: 1) the agency failed to ensure the patient and/or caregiver received education and training identified in the Plan of Care. Failure to provide appropriate education and training to patients and caregivers has the potential to result in negative patient outcomes. The hospice failed to provide education and training as evidenced by the following: Patient #1 – This 73-year-old patient with the terminal diagnosis of chronic obstructive pulmonary disease, unspecified was admitted to the hospice on 04/04/2025. Review of the Hospice Certification and Plan of Care dated 04/04/2025 to 07/02/2025 revealed an order for skilled nurse/caregiver/facility staff to apply A&D ointment or nursing cream every four (4) hours as needed. Cover with non-adherent dressing to promote comfort and wound healing to wound location on coccyx. Review of the Hospice Registered Nurse Subsequent Visit Note dated 04/07/2025 revealed the Registered Nurse documented the following:#1 Mid- coccyx, pressure ulcer I Change in status: none…Wound Care provided: skilled nurse/caregiver/facility staff to apply A&D ointment or nursing cream every four (4) hours as needed. Cover with non-adherent dressing to promote comfort and wound healing to wound located on the coccyx. Patient tolerated well.- Indicate teaching performed:o Infection control and prevention;o Covid-19 precautions and prevention;o Medication or treatment changes;o Falls prevention;o Oxygen use and safety including no smoking or open flames;o Future planning; ando Encouraged to call with any change in condition or symptom concerns.- Who was teaching provided to:o Patient- Was a demo/redemo completed today?o No During interview on 05/15/2025 at 09:18 AM, the Home Care Registered Nurse stated wound care education was discussed with the caregiver and should have been documented, including the demonstration and redemonstration of the wound care.”

“Based on review of clinical records and interviews with staff, for six (6) of twenty-seven (27) patients (Patient #’s: 7, 12, 15, 16, 17, and 18) the hospice failed to develop an individualized written Plan of Care that reflects the patient and family goals and is based on the problems identified in the initial and updated comprehensive assessments. Failure to develop complete, individualized plans of care has the potential for unmet patient needs and health status to be compromised, resulting in poor quality of care. The agency failed to develop complete and individualized plans of care as evidenced by the following: Patient #12 – This 100-year-old patient with a terminal diagnosis of sensile degeneration of brain, not elsewhere classified was admitted to the hospice on 04/16/2025.Review of the Hospice RN (Registered Nurse) Subsequent Visit dated 05/02/2025 revealed the Registered Nurse documented the following:IntegumentaryIndicate Integumentary Assessment Findings: Erythema, Pale, Poor Turgor, and Other (Specify).Indicate Location of Erythema: bilateral buttocks, blanchable, no open wounds. Staff applying vitamin A and D ointment.Review of the clinical record lacked documented evidence of an order for the use of vitamin A and D ointment.During an interview on 05/14/2025 at 12:58 PM, the Facility Based Services Team 7 Manager stated that it “looks like we don’t have an order for the vitamin A and D ointment.” Patient #16 – This 99-year-old patient with a terminal diagnosis of unspecified diastolic (congestive) heart failure was admitted to the hospice on 04/18/2025. Review of the Hospice Certification and Plan of Care for certification period 04/18/2025 to 07/16/2025 revealed the following order: hospice nurse/caregiver to clean area around cholecystectomy insertion site with alcohol pad, flush tubing with 10 ml and drain the collection bag twice daily and change connection tube and bag every three weeks. There is a lack of documented evidence of what the cholecystectomy tube should be flushed with.During an interview on 05/14/2025 at 01:04 PM, the Chief of Clinical Operations stated that the order should have what to flush the cholecystectomy tube with and the order would have to be clarified with the Registered Nurse.During an interview on 05/14/2025 at 03:35 PM, the Admissions Registered Nurse stated, “I feel like the family had all the supplies in the home and were managing the cholecystectomy tube” and that “I don’t recall what they were using to flush the cholecystectomy tube with.” Patient #15 – This 75-year-old patient with the terminal diagnosis of unspecified combined systolic and diastolic (Congestive) heart failure was admitted to the hospice on 04/19/2025.A. Review of the Hospice Certification and Plan of Care dated 04/19/2025 to 07/17/2025 revealed an order for Systane Preservative Free (PF) 0.4%-0.3% eye drops in a dropperette, one (1) dropperette single-use drop dispenser daily. The medication order for Systane Preservative Free (PF) 0.4%-0.3% eye drops lacked instructions for which eye to apply the medication.During interview on 05/14/2025 at 02:28 PM, the Chief of Clinical Operations stated the instructions should include which eye the medication is to be applied to and does not.B. Review of the Hospice Certification and Plan of Care dated 04/19/2025 to 07/17/2025 revealed an order for Hospice nurse to instruct and monitor use of oxygen. Patient, primary caregiver, skilled nurse to apply two (2) – four (4) liters via nasal cannula as needed for comfort and shortness of breath.The Hospice Certification and Plan of Care lacks an order for oxygen tubing and supplies.During interview on 05/14/2025 at 02:30 PM, the Chief of Clinical Operations stated the oxygen tubing and supplies should be included in the orders. Patient #7 – This 89-year-old patient with the terminal diagnosis of cerebrovascular disease, unspecified was admitted to the hospice on 04/14/2025.Review of the Hospice Certification and Plan of Care dated 04/14/2025 to 07/12/2025 revealed an order for Brimonidine 0.2% eye drops one (1) drop two (2) times daily.The order for the Brimonidine 0.2% eye drops lacks instructions on whether the eye drops are to be applied to the left, right or both eyes.During interview on 05/14/2025 at 02:15 PM, the Chief of Clinical Operations stated that it is not clear and would be expected that the instructions would include which eye or both eyes medication is to be applied. Patient #17 – This 91-year-old patient with the terminal diagnosis of unspecified combined systolic and diastolic (Congestive) heart failure was admitted to the hospice on 04/19/2025.Review of the Hospice Certification and Plan of Care dated 04/19/2025 to 07/17/2025 revealed orders for the following:- Brimonidine 0.2% - Timolol 0.5% eye drops one (1) drop daily;- Dorzolamide 2% eye drops one (1) drop daily; and - Rocklatan 0.02%-0.005% eye drops one (1) drop at bedtime. The orders for Brimonidine, Dorzolamide, and Rocklatan lacks instructions on whether the eye drops are to be applied to the left, right or both eyes.During interview on 05/14/2025 at 02:35 PM, the Chief of Clinical Operations stated it is not clear what eye(s) the medication is to be applied and is expected to be included in the instructions for the medications. Patient #18 – This 99-year-old patient with the terminal diagnosis of malignant neoplasm of the prostate was admitted to the hospice on 04/04/2025.Review of the Hospice Certification and Plan of Care dated 04/18/2025 to 07/16/2025 revealed an order for miralax 17 gram oral powder packet, 17 gram daily as needed for constipation. The order lacks instructions that include how to take the Miralax powder.During interview on 05/14/2025 at 02:41 PM, the Chief of Clinical Operations stated that it is not clear how the powder should be taken and the instructions should have included to mix in water.”

“Based on clinical record review and interview with agency staff, for seven (7) of twenty-seven (27) patient records (Patient #: 1, 9, 12, 13, 14, 23, and 24), the hospice failed to ensure records are complete and contain all pertinent information related to the care and delivery of service to the patient. Failure to ensure clinical records are complete and contain all pertinent information related to patient care and services has the potential to result in inadequate and inappropriate care. The Hospice failed to ensure records are complete and contain all pertinent patient information as evidenced by the following: Patient #23 – This 78-year-old patient with a terminal diagnosis of cerebrovascular disease with recent cerebrovascular accident (CVA) was admitted to the hospice on 10/1/2024.A. Review of the Registered Nurse Hospice PRN Visit – As Needed dated 10/05/2024 revealed the Registered Nurse documented the following:“Indicate problems/concern reported: patient’s daughter questions if “menuca” honey should be used on the stage 2 coccyx wound.”“Visit overview/plan for visit: on-call visit to assess coccyx wound for possible wound change to include “minooka” honey.“Collaborated with doctor written for new orders for wound care to coccyx to include “minocha” honey.”“New orders or treatments this visit: Skilled Nurse/Wife to cleanse coccyx wound with normal saline, pat dry, apply a thin layer of “minooka” honey, place allevyn every 3 to 5 days or as needed if loose or soiled to promote healing and prevention of infection”“Indicate supplies left in the home this visit: Manuka honey, 5x5 allevyn, 4x4 gauze, normal saline.”During interview on 5/14/2025 at 11:02 AM, the Chief of Clinical Operations stated that the discrepancies in the treatment with manuka honey was a typographical error likely caused by the Registered Nurse using talk to text while documenting.B. Review of the skilled nursing facility form titled ‘Medical Patient Instructions for Continuity of Care’ dated 10/01/2024 revealed the following medication order: “Esomeprazole Magnesium 40 delayed release capsule.”Review of the Registered Nurse Hospice Admission Visit dated 10/01/2024 revealed the following documentation “pre-admission medications discontinued or changed: discontinued this visit omeprazole.”During interview on 5/14/2025 at 10:58 AM, the Chief of Clinical Operations stated that the Registered Nurse most likely made a transcription error and the medication that was discontinued at start of care was Esomeprazole Magnesium. Patient #9 – This 88-year-old patient with a terminal diagnosis of end-stage Chronic Obstructive Pulmonary Disease (COPD) with hypoxic respiratory failure was admitted to the hospice on 4/19/2025.Review of the Skilled Nurse Hospice Revisit note dated 05/01/2025 revealed the following documentation regarding the patient’s pain assessment:“Alleviating factors: repositioning, rest, morphine”“Is this patient receiving opioid medication: No”During interview on 5/14/2025 at 9:41 AM, the Registered Nurse stated “no” must have accidentally been pressed instead of “yes” while documenting on the tablet. The patient was receiving opioids for pain management. Patient #14 – This 78-year-old patient with a terminal diagnosis of end-stage high-grade serous carcinoma of the ovary involving pleura with a malignant pleural effusion and abdominal carcinomas was admitted to the hospice on 4/18/2025.Review of the Aide Hospice Visit note dated 05/02/2025 revealed the following:“Service: observe and report. Completed: Yes Note: Nothing to report”Review of the Skilled Nurse Hospice Revisit note dated 05/02/2025 revealed the following:“Home Health Aide contact this reporter informing of no void since last night, fourteen (14) hours.”During interview on 5/14/2025 at 11:37 AM, the Home Health Aide stated that documentation was completed during visit in real time and once the aide went to leave the patient disclosed that they had not voided. The nurse was then notified after the visit, but the home health aide had forgotten to update charting to reflect reporting of information. Patient #24 – This 53-year-old patient with a terminal diagnosis of colorectal cancer metastatic to lung and liver with a large fungating rectal mass was admitted to the hospice on 9/26/2023.Review of the Hospice Registered Nurse Subsequent Visit note dated 10/11/2023 revealed the following: “medication: nature’s bounty acidophilus probiotic 100 million colony forming units.” The visit note lacked complete documentation for the indication of initiating the probiotic at this visit.During interview on 5/14/2025 at 10:19 AM the clinician was unavailable for interview. The Chief of Clinical Operations stated that care was planned around gastrointestinal symptoms and assumes the medication was ordered to manage excessive bowel movements. The Chief of Clinical Operations further confirmed that agency expectation would be to indicate why the medication was initiated in the clinical record, and it is likely that the clinician forgot to include this information while documenting. Patient #1 – This 73-year-old patient with the terminal diagnosis of chronic obstructive pulmonary disease, unspecified was admitted to the hospice on 04/04/2025.Review of the Registered Nurse Hospice Admission Visit dated 04/04/2025 revealed the Registered Nurse documented the patient has a stage 1 pressure ulcer on the mid-coccyx, identified as wound #1. Review of the Registered Nurse PRN (as needed) Visit Note dated 04/13/2025 revealed the Registered Nurse documented the patient’s wound #1, mid-coccyx pressure ulcer as a Stage I. Review of the Hospice Registered Nurse Subsequent Visit Note dated 04/14/2025 revealed the Registered Nurse documented wound #1, mid- coccyx was a stage III pressure ulcer.The documentation regarding the stage of the wound is inconsistent.During interview on 05/15/2025 at 09:37 AM, the Registered Nurse stated that the stage of the pressure ulcer (stage III) was documented in error on 04/14/2025. Patient #12: This 100-year-old patient with a terminal diagnosis of sensile degeneration of brain, not elsewhere classified was admitted to the hospice on 04/16/2025. Review of the RN (Registered Nurse) Hospice Admission Visit dated 04/16/2025 revealed the Registered Nurse documented the following mid upper arm circumference (MUAC): “MUAC 18.5 cm today.” There is no documentation to state which arm was measured. During an interview on 05/14/2025 at 12:55 PM, the Registered Nurse stated that MUAC is mid upper arm circumference. The Registered Nurse continued to state, “I don’t recall which arm that I took the patient’s mid upper arm circumference.” Patient #13: – This 83-year-old patient residing in a skilled nursing facility (SNF) with a terminal diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung was admitted to the hospice on 04/15/2025. Review of the RN (Registered Nurse) Admission Visit dated 04/15/2025 revealed the Registered Nurse documented the following:Medication ReconciliationPre-admission medication list reviewed with the hospice medical director.Indicate information reviewed: Facility MAR (Mediation Administration Record).Pre-admission medications discontinued: meds (medications) discontinued at this time. No medications are listed. During an interview on 05/14/2025 at 12:25 PM, the Chief of Clinical Operations stated that the registered nurse reconciled the medications with the facility MAR (medication administration record) and that the documentation regarding medications that were discontinued was a typographical error as there were no medications discontinued.”

“Based on review of clinical records and interviews with agency staff, the agency failed for sixteen (16) of twenty-seven (27) (Patient #’s: 1, 3, 4, 6, 9, 10, 13, 14, 15, 16, 19, 20, 23, 24, 26, and 27) to ensure all documentation by professional staff is appropriately authenticated in accordance with accepted standards of practice. Failure to authenticate documentation with professional credentials has the potential for patients to receive care from unlicensed staff. The hospice failed to ensure that all documentation by professional staff is appropriately authenticated as evidenced by the following: Patient #3 – This 92-year-old patient with a terminal diagnosis of unspecified diastolic (congestive) heart failure was admitted to the hospice on 04/19/2025.Review of the Aide Hospice Visit dated 04/22/2025, 04/23/2025, 04/24/2025, 04/25/2025, 04/28/2025, 04/29/2025, 04/30/2025, 05/01/2025, 05/02/2025, and 05/05/2025 lacked documented evidence of the paraprofessional’s credentials.During an interview on 05/14/2025 at 12:24 PM, the Chief of Clinical Operations stated that the lack of credentials is a system problem and that the problem will be fixed.During an interview on 05/14/2025 at 02:04 PM, the Vice President of Clinical Education and Patient Advocacy stated the employee is a Home Health Aide. Patient #13 – This 83-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung was admitted to the hospice on 04/15/2025. A. Review of the RN (Registered Nurse) Hospice Admission Visit dated 04/15/2025 lacked documented evidence of the professional’s credentials. During an interview on 05/14/2025 at 12:24 PM, the Chief of Clinical Operations stated that the employee is a Registered Nurse and that the lack of credentials is a system problem and that the problem will be fixed.B. Review of the Aide Hospice Visit dated 04/18/2025, 04/21/2025, 04/23/2025, 04/25/2025, 04/28/2025, and 04/30/2025 lacked documented evidence of the paraprofessional’s credentials. During an interview on 05/14/2025 at 12:24 PM, the Chief of Clinical Operations stated that the employee is a Home Health Aide and that the lack of credentials is a system problem and that the problem will be fixed. Patient #16 – This 99-year-old patient with a terminal diagnosis of unspecified diastolic (congestive) heart failure was admitted to the hospice on 04/18/2025. A. Review of the Aide Hospice Visit dated 04/25/2025, 04/28/2025, 04/30/2025, 05/02/2025, and 05/05/2025 lacked documented evidence of the paraprofessional’s credentials.During an interview on 05/14/2025 at 01:00PM, the Chief of Clinical Operations stated that the employee is a Home Health Aide and that there are no credentials next to the employee’s electronic signature on the employee’s documentation.B. Review of the LPN (Licensed Practical Nurse) Visit dated 04/25/2025 lacked documented evidence of the professional’s credentials.During an interview on 05/14/2025 at 01:00 PM, the Chief of Clinical Operations stated that the employee is a Licensed Practical Nurse and that there are no credentials next to the employee’s electronic signature on the employee’s documentation.Patient #26 – This 80-year-old patient with a terminal diagnosis of cerebrovascular disease, unspecified was admitted to the hospice on 05/29/2024.A. Review of the LPN (Licensed Practical Nurse) Visit dated 05/31/2024, 06/04/2024, 06/05/2024, 06/06/2024, 06/07/2024, 06/10/2024, and 06/11/2024 lacked documented evidence of the professional’s credentials.During an interview on 05/14/2025 at 12:46 PM, the Chief of Clinical Operations stated that the employee is a Licensed Practical Nurse and there are no credentials next to the employee’s electronic signature.B. Review of the Aide Hospice Visit dated 06/03/2024, 06/05/2024, 06/07/2024, 06/10/2024, 06/12/2024, and 06/14/2024 lacked documented evidence of the paraprofessional’s credentials.During an interview on 05/14/2025 at 12:47 PM, the Chief of Clinical Operations stated that the employee is a Home Health Aide and there are no credentials next to the employee’s electronic signature on the employee’s documentation. Patient #1 – This 73-year-old patient with the terminal diagnosis of chronic obstructive pulmonary disease, unspecified was admitted to the hospice on 04/04/2025.A. Review of the Inpatient Unit Licensed Practical Nurse Subsequent Visit Note dated 05/03/2025 at 12:28 AM lacked the credentials for the employee.During interview on 05/14/2025 at 02:09 PM, the Chief of Clinical Operations stated the employee is a licensed practical nurse. Additionally, there is a system error that did not include the credentials with the signature of the employee. B. Review of the Aide Hospice Inpatient Visit Note dated 05/05/2025 at 02:24 PM revealed the note for the aide contains the credentials for a Registered Nurse, not an aide. During interview on 05/14/2025 at 02:07 PM, the Chief of Clinical Operations stated the employee is not a Registered Nurse but is employed as a Home Health Aide. Additionally, the Registered Nurse credentials were included in error and should have been documented as Home Health Aide. C. Review of the Aide Hospice Inpatient Visit Note dated 04/30/2025 at 06:22 AM lacked the credentials for the employee.D. Review of the Aide Hospice Inpatient Visit Note dated 04/30/2025 at 10:30 PM lacked the credentials for the employee.E. Review of the Aide Hospice Inpatient Visit Note dated 05/01/2025 at 05:56 AM lacked the credentials for the employee.F. Review of the Aide Hospice Inpatient Visit Note dated 05/01/2025 at 10:30 PM lacked the credentials for the employee.G. Review of the Aide Hospice Inpatient Visit Note dated 05/03/2025 at 10:37 PM lacked the credentials for the employee.H. Review of the Aide Hospice Inpatient Visit Note dated 05/04/2025 at 02:03 PM lacked the credentials for the employee.I. Review of the Aide Hospice Inpatient Visit Note dated 05/05/2025 at 09:45 PM lacked the credentials for the employee.During interview on 05/14/2025 at 02:06 PM, the Chief of Clinical Operations stated employees are Home Health Aides. Additionally, there are no credentials next to the employee’s electronic signature on the employee’s documentation. Patient #15 – This 76-year-old patient with the terminal diagnosis of unspecified combined systolic and diastolic (congestive) heart failure was admitted to the hospice on 04/19/2025.Review of the Chaplain Hospice Add-On Evaluation Visit dated 04/22/2025 lacked documented evidence of employee HH’s professional credentials.During interview on 05/14/2025 at 02:31 PM, the Chief of Clinical Operations stated there is a system error and the chaplain credentials should have been included with the signature. Patient #9 – This 88-year-old patient with a terminal diagnosis of end-stage Chronic Obstructive Pulmonary Disease (COPD) with hypoxic respiratory failure was admitted to the hospice on 4/19/2025.A. Review of the Aide Hospice Visits dated 4/23/2025, 4/25/2025, 4/28/2025, 4/30/2025, 5/2/2025, and 5/5/2025 lacked documented evidence of the paraprofessional’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 11:24 AM, the Chief of Clinical Operations verified that employee BBB is a Home Health Aide.B. Review of the On Call note dated 5/2/2025 lacked documented evidence of the professional’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 11:24 AM, the Chief of Clinical Operations verified that employee CCC is a Licensed Practical Nurse.C. Review of the On Call note dated 4/27/2025 lacked documented evidence of the professional’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 11:24 AM, the Chief of Clinical Operations verified that employee LL is a Licensed Practical Nurse.D. Review of the Home Health Aide Schedule Update note dated 4/22/2025 lacked documented evidence of the employee’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 11:24 AM, the Chief of Clinical Operations verified that employee OO is a Team Scheduler.E. Review of the Medication Recommendations note dated 4/21/2025 lacked documented evidence of the professional’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 11:24 AM, the Chief of Clinical Operations verified that employee AA is the Pharmacy Director.F. Review of the Volunteer Care Plan note dated 4/24/2025 lacked documented evidence of the employee’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 11:24 AM, the Chief of Clinical Operations verified that employee NN is a Coordinator Volunteer Services. Patient #24 – This 53-year-old patient with a terminal diagnosis of colorectal cancer metastatic to lung and liver with a large fungating rectal mass was admitted to the hospice on 9/26/2023.A. Review of the Aide Hospice Visits dated 11/14/2023 and 11/15/2023 lacked documented evidence of the paraprofessional’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 10:40 AM, the Chief of Clinical Operations verified that employee QQ is a Home Health Aide. B. Review of the Aide Hospice Visit dated 11/14/2023 lacked documented evidence of the paraprofessional’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 10:40 AM, the Chief of Clinical Operations verified that employee PP is a Home Health Aide. C. Review of the Aide Hospice Visit dated 11/14/2023 lacked documented evidence of the paraprofessional’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 10:40 AM, the Chief of Clinical Operations verified that employee RR is a Home Health Aide.D. Review of the Aide Hospice Visit dated 11/13/2023 lacked documented evidence of the paraprofessional’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 10:40 AM, the Chief of Clinical Operations verified that employee SS is a Home Health Aide. Patient #6 – This 87-year-old patient with a terminal diagnosis of stage IV (four) squamous cell carcinoma of the larynx involving esophagus and lung was admitted to the hospice on 4/19/2025. A. Review of the Aide Hospice Visits dated 11/14/2023 lacked documented evidence of the paraprofessional’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 10:40 AM, the Chief of Clinical Operations verified that employee PP is a Home Health Aide. B. Review of the Chaplain Add-on Evaluation Visit dated 4/23/2025 lacked documented evidence of the employee’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 11:20 AM, the Chief of Clinical Operations verified that employee HH is a Chaplain. Patient #14 – This 78-year-old patient with a terminal diagnosis of end-stage high-grade serous carcinoma of the ovary involving pleura with a malignant pleural effusion and abdominal carcinomas was admitted to the hospice on 4/18/2025.A. Review of the Aide Hospice Visits dated 4/24/2025, 4/25/2025, 4/28/2025, 4/29/2025, 4/30/2025, 5/1/2025, 5/2/2025, 5/5/2025, and 5/6/2025 lacked documented evidence of the paraprofessional’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 11:46 AM, the Chief of Clinical Operations verified that employee JJ is a Home Health Aide.B. Review of the Phone Call Check notes dated 5/4/2025, 5/4/2025, and 5/5/2025 lacked documented evidence of the paraprofessional’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 11:46 AM, the Chief of Clinical Operations verified that employee LL is a Licensed Practical Nurse.C. Review of the Master of Social Work Add-on Evaluation visit dated 4/18/2025 lacked documented evidence of the professional’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 11:46 AM, the Chief of Clinical Operations verified that employee KK is a Social Worker.D. Review of the Home Health Aide Schedule Update note dated 4/23/2025 lacked documented evidence of the employee’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 11:46 AM, the Chief of Clinical Operations verified that employee MM is a Coordinator Home Health Aide Services. Patient #23 – This 78-year-old patient with a terminal diagnosis of cerebrovascular disease with recent cerebrovascular accident (CVA) was admitted to the hospice on 10/1/2024.A. Review of the Medication Recommendations note dated 10/2/2024 lacked documented evidence of the professional’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 10:57 AM, the Chief of Clinical Operations verified that employee AA is the Pharmacy Director.B. Review of the Tuck In Call note dated 10/1/2024 lacked documented evidence of the professional’s credentials.During an interview on 05/14/2025 at 9:29 AM, the Chief of Clinical Operations stated that the lack of credentials is a system issue and that the problem will be fixed.During an interview on 05/14/2025 10:57 AM, the Chief of Clinical Operations verified that employee CCC is a Licensed Practical Nurse. Patient #27- This 87-year-old patient with a terminal diagnosis of alzhiemer’s disease, unspecified was admitted to the hospice on 05/16/2024. A. Review of the Registered Nurse Hospice Admissions Visit Note dated 05/16/2024 lacks documented evidence of Employee BB’s professional credentials.B. Review of the Licensed Practical Nurse Visits dated 05/27/2025 lacks documented evidence of Employee EE’s professional credentials.C. Review of the Licensed Practical Nurse Visits dated 05/29/2025, 05/30/2025 and 05/31/2025 lacks documented evidence of Employee FF’s professional credentials.D. Review of the Licensed Practical Nurse Visits dated 06/04/2025 lacks documented evidence of Employee YY’s professional credentials.E. Review of the Licensed Practical Nurse Visits dated 06/05/2025 lacks documented evidence of Employee ZZ’s professional credentials. Patient #20- This 83-year-old patient with a terminal diagnosis of cerebral vascular disease, unspecified was admitted to the hospice on 04/15/2025. A. Review of the Registered Nurse Hospice Admissions Visit Note dated 04/15/2025 lacks documented evidence of Employee BB’s professional credentials.B. Review of the Home Health Aide Visits dated 04/17/2025, 04/22/2025, 04/24/2025, 04/29/2025, and 05/01/2025 lacks documented evidence of Employee EEE’s professional credentials.C. Review of the Medical Social Worker Visits dated 04/16/2025, and 04/21/2025 lacks documented evidence of Employee KK’s professional credentials. Patient #4- This 87-year-old patient with the terminal diagnosis of chronic obstructive pulmonary disease, unspecified was admitted to the hospice on 02/03/2025. A. Review of the Licensed Practical Nurse Visits dated 02/26/2025 and 04/28/2025 lacks documented evidence of Employee EE’s professional credentials.B. Review of the Licensed Practical Nurse Visits dated 05/05/2025 lacks documented evidence of Employee YY’s professional credentials. Patient #10- This 66-year-old patient with a terminal diagnosis of malignant neoplasm of the brain, unspecified was admitted to the hospice on 04/15/2025.Review of the Medical Social Worker Visit dated 04/15/2025 lacks documented evidence of Employee DDD’s professional credentials. Patient #19- This 64-year-old patient with a terminal diagnosis of senile degeneration of the brain, not elsewhere classified was admitted to the hospice on 04/18/2025.Review of the Home Health Aide Visits dated 04/25/2025, 04/28/2025, 04/30/2025, 05/02/2025, and 05/05/2025 lacks documented evidence of Employee CC’s professional credentials. During interview on 05/14/2025 at 09:30 AM, the Chief of Clinical Operations stated that this is an issue with the system when the employee electronic signatures are developed. Additionally, the Chief of Clinical Operations stated that all staff should have titles included in the signatures.”

“Based on clinical record review and staff interview for one (one) of three (3) live discharged patients (Patient #23). the hospice failed to ensure a comprehensive discharge summary was prepared that contained all required components. Failure to prepare a comprehensive discharge summary places patients at risk for poor coordination of patient services and unmet patient needs upon discharge/transfer from the hospice.The hospice failed to prepare a comprehensive discharge summary as evidenced by the following: Patient #23 – This 78-year-old patient with a terminal diagnosis of cerebrovascular disease with recent cerebrovascular accident (CVA) was admitted to the hospice on 10/1/2024.Review of the Hospice Revocation and Clinical Note dated 10/17/2024 revealed the patient was revoking the hospice benefit to pursue restorative therapies.Review of the clinical record lacked documented evidence that a comprehensive discharge summary was prepared at the time of discharge.During interview on 05/14/2025 at 10:56 AM, the Home Care Services Team 4 Manager stated the agency expectation is for all live discharges to have discharge summaries. The Home Care Services Team 4 Manager confirmed that this patient did not have a discharge summary prepared, that the agency is aware, and they are implementing internal changes to ensure compliance.”