Rochester Regional Health Hospice Care

“Based on review of clinical records and staff interview, two (2) of five (5) patients (Patient #’s: 2 and 4), 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: Patient #2 – This 55-year-old patient with the terminal diagnosis of fallopian tube cancer was admitted to the inpatient hospice unit on 12/20/2024. Review of the Initial Visit Note dated 12/20/2024 revealed the Registered Nurse documented the following: “;request hospice chaplain visit.” Review of the Clinical Note dated 12/26/2024 revealed the first Chaplain Visit was completed on 12/26/2024, six (6) days after the start of care and request for Chaplain services. During interview on 01/08/2025 at 11:32 AM, the Assistant Director of the inpatient hospice care center stated the Chaplain did not see the patient within five (5) days of the start of care. Patient #4 – This 62-year-old patient with a terminal diagnosis of right small cell lung carcinoma was admitted to the hospice on 10/04/2024. Review of the New Admission Clinical Note dated 10/04/2024 revealed the Registered Nurse documented the patient and family elected to have Skilled Nursing, Social Work and Pastoral Care services. Review of Medical Social Services Clinical Note dated 10/16/2024 revealed the first Social Work contact with the patient/family occurred on 10/16/2024 when the Social Worker offered emotional support during a telephone call to the patients spouse. During interview on 01/08/2025 at 09:15 AM, the Assistant Director of Hospice and Palliative Care stated the Social Worker had been assigned upon the patients admission to the hospice but an error occurred and the Social Worker failed to initiate services within five (5) days of the election to hospice.”

“Based on review of clinical records and staff interview, for one (1) of five (5) patients (Patient #2) the agency failed to manage the patient’s symptoms. Failure to manage the patient’s symptoms can potentially result in the development of an incomplete plan of care, and negative patient outcomes. The agency failed to manage the patient’s symptoms as evidenced by: Patient #2 – This 55-year-old patient with the terminal diagnosis of fallopian tube cancer was admitted to the inpatient hospice unit on 12/20/2024. Review of the Routine Visit Note dated 12/24/2024 revealed the Registered Nurse documented the following: “;breathing- labored.” Review of the clinical record lacks documented evidence the Registered Nurse implemented interventions to manage the patients labored breathing. During interview on 01/08/2025 at 11:32 AM, the Registered Nurse One stated the patient is on a dilaudid pump for symptom management but she did not educate the patient on using boluses as needed to relieve the labored breathing.”

“Based on review of clinical records and interview with agency staff, for one (1) of five (5) patients (Patient #4), the hospice failed to ensure the clinical record is complete and contains all pertinent information related to responses to medications, symptom management, treatments, and services. Failure to ensure clinical records are complete contain all pertinent/ accurate information related to responses to medications, symptom management, treatments, and services has the potential to result in inadequate and inappropriate care. The hospice failed to ensure clinical records contain all information related to responses to medications, symptom management, treatments, and services as evidenced by the following: Patient #4 – This 62-year-old patient with a terminal diagnosis of right small cell lung carcinoma was admitted to the hospice on 10/04/2024. Review of the Routine Visit Note dated 10/07/2024 revealed the Registered Nurse documented instructing the patients spouse on the comfort care medications and instructed to use morphine 0.5 milliliter for any breakthrough pain the patient may have. Additionally, the Registered Nurse suggested the spouse try administering levsin to the patient at bedtime and would conduct follow-up with the spouse the following day to see if the medication helped. Review of the clinical record lacks documentation of any follow-up with the patient/ spouse on 10/08/2024 and revealed the next Registered Nurse contact occurred at the 10/10/2024 visit. During interview on 01/08/2025 at 10:20 AM, the Assistant Director of Hospice and Palliative Care stated the Registered Nurse is out on a medical leave and is unable to be interviewed. The Assistant Director of Hospice and Palliative Care stated the Registered Nurse failed to follow-up with the patients spouse on 10/08/2024.”

“Based on review of clinical records and interview with agency staff, the hospice failed to ensure in one (1) of twenty-seven (27) clinical records (Patient #7) the content of the comprehensive assessment is of sufficient scope to identify all of the patient’s needs in order 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 hospice failed to ensure assessments are comprehensive as evidenced by the following: Patient #7 – This 80-year- old patient, residing in a skilled nursing facility, with a terminal diagnosis of senile degeneration of the brain was admitted to the hospice on 01/09/2024. Review of the Skilled Nursing Facility Treatment Administration Record from 01/01/2024 to 01/31/2024 revealed the patient is ordered to wear compression stockings daily, applied in the morning and removed at bedtime. Review of the Skilled Nursing Facility Home Health Aide Care Plan dated 01/09/2024 revealed the hospice aide is assigned the task of applying thromboembolism-deterrent (TED) stockings every morning and removing them every evening. Review of the Initial Visit dated 01/09/2024, made by the Registered Nurse, lacks documentation of an assessment of the compression stockings, application and patient tolerance. During interview on 03/27/2024 at 10:25 AM, the Registered Nurse acknowledged she failed to include an assessment of the compression stockings the patient was using during the identified visit.”

“Based on review of clinical records, agency policies and procedures, and interview with staff, for five (5) of twenty-seven (27) patients (Patient #’s: 16,17, 23, 25, and 26), the hospice failed to ensure that nursing staff complete an accurate and comprehensive drug 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 (IDG) to act on inaccurate information. The hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review as evidence by: Patient #17 – This 67-year-old with a terminal diagnosis of malignant neoplasm of unspecified part of left bronchus of lung was admitted to the agency on 03/05/2024. Review of the Initial Visit dated 03/05/2004 revealed the Registered Nurse documented that there were no discrepancies with the medical reconciliation. A.) Review of the discharge summary dated 03/03/2024 revealed the following medication orders: - Fish oil-omega-3 fatty acids 1,000 milligram capsule; - Sulfamethoxazole-trimethoprim 400-800 milligram, oral, tablet, three times weekly; - Sulfamethoxazole-trimethoprim 800-160 milligram, oral, tablet, three times weekly; - Atorvastatin 40 milligram tablet; - Osteo Bi-Flex Oral 1 (one) capsule daily; - Varenicline 1 (one) milligram tablet, two times daily. Review of the Physicians Orders/Plan of Care dated 03/05/2024 revealed there are no orders for the identified medications. Review of the Interdisciplinary Group Meeting Notes dated 03/07/2024 revealed there is no documentation of a discussion regarding the need to discontinue the medications. B.) Review of the discharge summary dated 03/03/2024 revealed stop orders for the following medications. - Promethazine 12.5 milligram tablet. Review of the Physicians Orders/Plan of Care dated 03/05/2024 revealed an order for the identified medication. Review of the Interdisciplinary Group Meeting Notes dated 03/07/2024 revealed there is no documentation of a discussion regarding the need to continue the medication. During interview on 03/27/2024 at 11:31 AM, the Registered Nurse stated that she compares the discharge summary with what the patient has on hand and those are the medications that go on to the hospice orders. Patient #16- This 95-year-old patient with a terminal diagnosis of alzheimers disease was admitted to the hospice on 03/05/2024. A.) Review of the After Visit Summary dated 02/29/2024 revealed the following medication orders: - Cholecalciferol (vitamin D3) 25 microgram (1,000 unit) chewable take one (1) tablet by mouth daily; - Diclofenac sodium 1% gel apply one (1) application topically four (4) times daily. Apply four (4) grams with each application; and - Econazole nitrate 1% cream apply under the breast area bilaterally two (2) times daily. Review of the Physicians Orders/Plan of Care from 03/05/2024 to 06/02/2024 lacks orders for Cholecalciferol, Diclofenac sodium gel, and Econazole nitrate cream. Review of the clinical record lacks documented evidence that the physician was contacted regarding the medication discrepancies identified. During an interview on 03/26/2024 at 11:52 AM, the Registered Nurse did discuss the identified discrepancy with the doctor but, failed to document this. B.) Review of the After Visit Summary dated 02/29/2024 revealed the following medication orders: - Senna 8.6 milligram tablet take two (2) tablets by mouth at bedtime; and - Melatonin 10 milligram tablet take one (1) tablet by mouth at bedtime. Review of the Physicians Orders/Plan of Care from 03/05/2024 to 06/02/2024 revealed the following medication orders: - Senna by mouth tablet 8.6 milligram two (2) tablets every evening by mouth as needed for constipation; and - Melatonin by mouth tablet 10 milligram one (1) tablet every evening by mouth as needed for sleep. Review of the clinical record lacks documented evidence that the physician was contacted regarding the medication discrepancies identified. During an interview on 03/26/2024 at 11:52 AM, the Registered Nurse did discuss the identified discrepancy with the doctor but, failed to document this. Patient #23 This 97-year-old patient, residing in a skilled nursing facility, with a terminal diagnosis of alzheimers disease with late onset was admitted to the hospice on 03/03/2024. Review of the facility Medication Record for 03/2024 revealed the following medication orders: - Vitamin D3 25 micrograms (1,000 unit) tablet [cholecalciferol (vitamin D3] two (2) tablets by mouth once daily for bone health; and - Ocuvite eye plus multi 200 micrograms-15 micrograms- 150 microgram tablet [multivitamin, folic acid vitamin, vitamin K, lycopene, lutein, zeaxanthin] one (1) tablet by mouth once daily for macular degeneration. Review of the Physicians Orders/Plan of Care from 03/03/2024 to 05/31/2024 revealed the following medication orders: - Vitamin D by mouth tablet 25 microgram (1,000) unit two (2) tablets every day by mouth; and - Ocuvite eye plus multivitamin by mouth tablet one (1) tablet everyday by mouth for macular degeneration. Review of the clinical record lacks documented evidence that the physician was contacted regarding the medication discrepancies identified. During an interview on 03/27/2024 at 11:52 AM, the Registered Nurse stated uses orders on the facility list for the physicians orders/plan of care. Patient # 26 This 87-year-old patient, residing in a skilled nursing facility, with a terminal diagnosis of dysphagia, pharyngoesophageal phase was admitted to the hospice on 03/04/2024. Review of the facility Medication Record for 03/2024 revealed the following medication orders: - Miralax 17 gram per dose oral powder [Polyethylene glycol 3350] give 17 grams in four (4) to eight (8) ounces of fluid by mouth once daily. Fill to line on cap (give in chicken broth) for constipation; - Clobetasol 0.05% topical ointment [generic] thin layer topical every 12 hours for fluid filled blisters on hands, feet, thighs, and back; - Eucerin original lotion [Lanolin-mineral oil] thin layer topical twice daily in am and at bedtime for xerosis; - Peridex 0.12% mouthwash [Chlorhexidine gluconate] 10 milliliters by mouth twice daily for gingivitis swish and spit in morning and at bedtime; - Naloxone 4 milligram/actuation nasal spray [generic] 4 milligram administer naloxone spray (four milligram), repeat dose in two minutes for unresponsiveness or difficulty breathing due to suspected opioid-induced respiratory depression, until individual is breathing (respiratory rate greater than 10). Initiate emergency medical response protocol (having security call 911) to transfer the resident to the hospital emergency department; - Geodon 40 milligram capsule give one (1) capsule (40 milligram) by mouth twice daily in the morning and at bedtime for bipolar disorder; - Flonase allergy relief 50 micrograms/actuation nasal spray, suspension [Fluticasone propionate] two (2) sprays in both nostrils once daily for postnasal drip or cough; and - Acetaminophen 500 milligram tablet [generic] give two (2) tablets (1,000 milligram) by mouth for pain. Review of the Physicians Orders/Plan of Care from 03/04/2024 to 06/01/2024 revealed the following medication orders: - Miralax by mouth 17 gram per scoop 17 gram; - Clobetasol propionate external ointment 0.05% *special instructions* every 12 hours external to bilateral hands; - Eucerin external lotion *special instructions* two (2) times a day external to back; - Peridex mouth/throat solution 0.12% 10 milliliter two (2) times a day mouth/throat; - Naloxone hydrochloride nose liquid 4 milligram/0.1 milliliter four (4) milligram *nose as needed for unresponsiveness, difficulty breathing; - Geodon by mouth capsule 40 milligram capsule two (2) times a day by mouth; - Flonase allergy relief nose suspension 50 microgram/actuation two (2) application everyday nose; and - Acetaminophen by mouth tablet 325 milligram two (2) tablets every four hours by mouth as needed for pain or fever. Review of the clinical record lacks documented evidence that the physician was contacted regarding the medication discrepancies identified. During an interview on 03/26/2024 at 02:41 PM, the Registered Nurse stated there should not be medication discrepancies between facility and physicians/plan of care orders. The hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review as evidence by: Patient #25 – This 87-year-old patient with the terminal diagnosis of malignant neoplasm of body of pancreas was admitted to the hospice on 02/14/2024. Review of the referral to the agency dated 02/14/2024 revealed the following medications:- docusate sodium 100 mg (milligram) capsules take three (3) to four (4) capsules by mouth at bedtime;- furosemide 40 milligram tablets take one (1) tablet by mouth every day as needed for 30 days; and -morphine 15 milligrams tablet take one (1) tablet by mouth every six (6) hours as needed. Review of the Physicians Order/ Plan of Care dated 02/14/2024 lacks orders for the identified medications. Review of the clinical record lacks documentation the Registered Nurse discussed the discrepancies with the physician or the Interdisciplinary Group. During interview on 03/26/2024 at 10:17 PM, the Registered Nurse stated she did call the patients physician but did not specify which medications were discontinued.”

“Based on review of clinical records, agency policy and procedure, and interviews with staff, the hospice failed for one (1) of (27) patients (Patients #18) to perform an initial bereavement assessment of the needs of the patient’s family and caregivers. Failure to perform a risk assessment for bereavement places the family and other individuals at risk for not receiving appropriate counseling and supportive services. The agency failed to ensure an initial bereavement assessment was performed as evidence by: Review of the agency’s policy entitled “Bereavement Counseling and Services” last approved 11/2023 revealed: “I. Bereavement risk factors are assessed by the hospice nurse and/or social worker and documented as part of the Comprehensive Assessment. II. Anticipatory grief and coping mechanisms are routinely assessed as part of the Interdisciplinary Group.” Patient #18 - This 66-year-old with a terminal diagnosis of follicular lymphoma grade ilia, extranodal and solid organ sites was admitted to the hospice on 03/05/2024. Review of the Registered Nurse Comprehensive Visit note dated 03/05/2024 lacks documented evidence that a bereavement risk assessment was performed for the patient’s family and/or caregivers. Review of the Social Worker Initial Visit note dated 03/07/2024 lacks documented evidence that a bereavement risk assessment was performed for the patient’s family and/or caregivers. Review of the Interdisciplinary Group Meeting Notes dated 03/21/2024 lacks evidence of a bereavement assessment. During interview on 03/27/2024 at 10:57 AM, the Social Worker stated the bereavement risk assessment was not documented because she missed it. The Assistant Director of Hospice and Palliative Care stated that a bereavement risk assessment should be done at every initial visit.”

“Based on clinical record reviews and staff interviews, five (5) of twenty-seven (27) clinical records (Patient #’s: 1, 10, 19, 20 and 27) lack evidence that the hospice nurses and Interdisciplinary Group members are performing complete updated comprehensive assessments or that the hospice nurses are communicating changes in the patient condition to the Interdisciplinary Group. Failure to ensure that comprehensive assessments are updated and reflect changes in the current status of the patient has the potential for the patient’s health status to be compromised and result in the provision of poor quality of care. The hospice failed to ensure comprehensive assessments are updated and changes communicated to the Interdisciplinary Group as evidenced by the following: Patient #10 – This 58-year-old patient with a terminal diagnosis of end stage chronic obstructive pulmonary disease was admitted to the hospice on 10/04/2023. A.) Review of the Clinical Note dated 10/04/2023 revealed the Social Worker documented that during the hospice evaluation that day the patient discussed suicide and became agitated. The Social Worker reinforced the hospice did not want the patient to hurt himself and the goal was to make him more comfortable. Additionally, the Social Worker spoke to the spouse who confirmed the patient had discussed slitting his throat the previous night, wanted to die by 10/10/2023 and keeps a knife next to his chair for protection. Upon discussion with the hospice Supervisor, the Social Worker was able to have the spouse put the knife away and the patient was agreeable to pursue hospice care, denying an active suicide plan. Review of the Social Work Initial Visit dated 10/04/2023 revealed a suicide risk assessment was conducted during the visit and the patient was determined to be at low suicide risk. Additionally, the Social Worker documented case communication occurred with the Skilled Nurse, but not the Attending Physician. Review of the Hospice Interdisciplinary Group Review Meeting dated 10/05/2023 lacks documentation of a discussion regarding the patient and spouses conversation and concerns regarding suicide identified during the Social Work assessment on 10/04/2023. During interview on 03/26/2024 at 11:47 AM, the Social Worker stated the Attending Physician and Interdisciplinary Group were not updated regarding the identified suicide conversation and concerns but should have been. B.) Review of the Routine Visit conducted by the Social Worker dated 10/05/2023 revealed the Social Worker documented the patient is not feeling well with an oxygen saturation of 63 currently using 10 liters of oxygen over the tracheostomy. Congestion is heard in the patients throat and coughing is occurring. The Social Worker contacted the hospice Nurse who spoke to the patient and spouse over the telephone speaker. The hospice Nurse instructed the patient to attempt suctioning the tracheostomy and instructed when the comfort kit arrives in home, to read instructions and take Morphine and Lorazepam. Additionally, the hospice Nurse instructed when the replacement Oxygen concentrator is delivered to ensure to use the humidification attached to it. Review of the clinical record lacks documentation of an updated assessment or follow-up until a routine nursing assessment was conducted on 10/11/2023, six (6) days after the patient experienced the change in status. Review of the clinical record lacks documentation the Interdisciplinary Group was updated regarding the identified change in patient status. During interview on 03/26/2024 at 12:50 PM, the Registered Nurse stated the patient should have been assessed prior to the 10/11/2023 routine nursing visit. Patient #20 – This 83-year-old patient, residing in a skilled nursing facility, with a terminal diagnosis of a right intertrochanteric hip fracture, complicated by limited mobility and pain was admitted to the hospice on 03/05/2024. Review of the Routine Visit dated 03/12/2024 revealed the Registered Nurse documented the patient has a new pressure ulcer to the right buttocks and the facility Nurse Practitioner was made aware of the wound. Review of the Routine Visit dated 03/18/2024 revealed the Registered Nurse documented the patient has a new pressure ulcer to the mid back in addition to the right buttocks pressure ulcer and updated the facility staff. Review of the skilled nursing facility treatment order dated 03/18/2024 revealed the following orders: - Stage II right buttocks pressure ulcer- wash with mild soap and water pat dry, apply barrier cream two (2) times daily and as needed; and - Mid-back, deep tissue injury- wash with mild soap and water, pat dry leave open to air. Position patient on left side, use wedge pillow to help off load pressure when patient is in bed. Review of the Interdisciplinary Group Review Meeting dated 03/19/2024 revealed the patient has a new “;possible deep tissue to mid back and stage 2 to right hip.” There is no documentation regarding the updated treatment interventions the skilled nursing facility has initiated for the two identified wounds. During interview on 03/27/2024 at 12:17 PM, the Registered Nurse stated the Interdisciplinary Group was not updated regarding the treatment plan for the two identified wounds. Patient #27 – This 82-year-old patient with the terminal diagnosis of malignant neoplasm of trigone of bladder was admitted to the hospice on 02/11/2024. Review of the Routine Visit Note dated 03/18/2024 revealed the Registered Nurse documented the patient had a stage two pressure ulcer on the sacrum and the dressing change was done. Additionally, the Registered Nurse documented she cleansed the wound with wound cleanser, patted dry and foam dressing was applied. Review of the clinical records lacked documented evidence of a discussion to the physician regarding the patient’s new sacral wound or treatment for the wound. During interview on 03/26/2024 at 01:09 PM, the Registered Nurse stated that she forgot to notify the physician about the new sacral wound but should have. The Registered Nurse added that the family had dressing supplies in the home that she used to perform the wound care. Patient #1- This 71-year-old patient with the terminal diagnosis of acute kidney failure, unspecified was admitted to the hospice on 03/05/2024. Review of the agencys policy entitled “;Wound and Ostomy Care Policy” dated 05/2023 revealed: “C. Wound Measurement a. 3. Depth is measured with sterile cotton tipped applicator at the deepest portion of wound to the skin surface. Wounds with no measurable depth are to be documented as (less than) <0.1 centimeter.” A. Review of Inpatient Unit Transfer Comprehensive Assessment dated 03/11/2024 revealed the Registered Nurse documented the following right buttocks wound measurement: length in centimeters: 7, width in centimeters: 5. The assessment lacks documentation of the depth of the wound. During interview on 03/26/2024 at 03:53 PM, the Registered Nurse stated that the wound was superficial and there was no depth, the Registered Nurse is aware of the agency policy and stated the wound depth was not documented. B. Review of Inpatient Unit Comprehensive Assessment dated 03/12/2024 revealed the Registered Nurse documented the following left heel wound measurement: length in centimeters: 4.5, width in centimeters: 5. The assessment lacks documentation of the depth of the wound. During interview on 03/26/2024 at 04:04 PM, the Registered Nurse stated, “;It was a closed wound, but I understand the policy, there is not a depth documented.” C. Review of Inpatient Unit Comprehensive Assessment dated 03/08/2024 revealed the Registered Nurse documented the following under Gastrointestinal: Last Bowel Movement: 03/01/2024 (7 days prior to visit); Gastrointestinal Assessment: Bowel Sounds- Present; Details: Not applicable. The assessment lacks documentation of follow up on patients bowel status. During interview on 03/26/2024 at 04:11 PM, the Registered Nurse stated that an abdominal assessment was not completed during the visit and the floor nurse reported that the patients bowel sounds were present. The Registered Nurse also stated the hospital medication administration record was reviewed, but there was no discussion with the floor nurse regarding if scheduled bowel medications were being administered as ordered. Patient #19- This 85-year-old patient with the terminal diagnosis of senile degeneration of the brain was admitted to the hospice on 02/29/2024. A. Review of the Charts/ Clinical Note dated 03/01/2024 reveled the Registered Nurse documented a telephone call with the patients primary caregiver who reported the following: “... Primary caregiver has not slept five (5) out of the past seven (7) days. Reports the patients sundowning is getting worse and worse. Primary caregiver gave Seroquel 25 milligrams at 1:00 PM, instead of the ordered 50 milligrams because in the past increasing the dose made the patient more agitated. The primary caregiver gave the patient another 25 milligrams of Seroquel at 4:00 PM and reports after those 2 doses the patient was wound up. The primary caregiver felt the patients medications needed to be changed completely and reported that the Dayvigo worked for the first two (2) nights and the night of the call it did not touch the patient. The Registered Nurse advised the primary caregiver to try alternating giving Ativan and Haldol, and the Registered nurse would request a visit by the case manager in the morning to go over all medications, and see what changes can be made or medications to be added...” Review of the clinical record from 03/01/2024 to 03/21/2024 lacked documented evidence that the Case Manager followed up with the patients primary caregiver regarding the patients condition and medication effectiveness. During interview on 03/27/2024 at 02:06 PM, the Registered Nurse (Case Manager) at first was unable to recall, but thinks a message was received from the on-call nurse regarding the patients primary caregivers concerns. The Registered Nurse stated that there have been lots of calls with the primary caregiver, but the Registered Nurse did not document them all. B. Review of Routine Visit Assessment dated 03/08/2024 revealed the Registered Nurse documented under “Emotional/ Behavior/ Sleep: Comments: patients caregiver reports increased agitation and restlessness late in the afternoon that continues into the wee hours of the morning, that Haldol intramuscularly and intravenously given in the hospital did nothing. The patients caregiver also stated that the on-call service was contacted late last night about midnight and the caregiver did not receive a call back for another hour, that the patient was given more Seroquel which was finally effective in calming the patient down.” Review of the Charts/ Clinical Notes dated 03/07/2024 revealed the Registered Nurse documented that the patients primary caregiver called into triage. The Registered Nurse attempted to call the primary caregiver back but there was no answer, the Registered Nurse left a voicemail to call 21-1000 regarding questions/ concerns. Review of the clinical record from 03/07/2024 to 03/21/2024 lacked documented evidence that the on-call nurse made any other attempts to follow up with the patients primary caregiver regarding the patients condition and medication effectiveness, or if any further contact was made. During interview on 03/28/24 at 09:33 AM, the Assistant Director of Hospice and Palliative Care stated that there was no further documentation that another attempt was made but the on-call nurse should have done this. C. Review of Routine Visit Assessment dated 03/08/2024 revealed the Registered Nurse documented in “Summary of Status: Comments: Patients caregiver was very anxious and gave a long confusing about what medications were given to the patient. The caregiver had been up most of the night and that the patients agitation started to escalate about 4:00 PM the day before, the caregiver gave the patient two (2) doses of Seroquel, but the patient was still agitated so the caregiver gave the patient clonazepam, then more Seroquel before finally giving the patient Dayvigo at 1:00 AM as a last resort. The caregiver could not clearly tell the Registered Nurse what medications were given, how much was given or when because the caregiver did not write anything down. The Registered Nurse provided detailed education about giving medications as ordered for desired effects and keeping a log of what medications are administered. The Registered Nurse documented that report was given to the case manager.” Review of the clinical record from 03/08/2024 to 03/21/2024 lacked documented evidence that the Case Manager followed up with the patients primary caregiver regarding the patients condition and medication management and effectiveness. During interview on 03/27/2024 at 09:03 AM, the Registered Nurse stated that report was given to the case manager in the evening on 03/08/2024 and also sent this communication to the scheduler in case another clinician was scheduled to see the patient sooner than the case manager. During interview on 03/27/2024 at 02:10 PM, the Registered Nurse (Case Manager) stated that there was a telephone call to the patients caregiver on 03/4/2024, and a visit was made to the patient on 03/20/2024, but the Registered Nurse was on vacation from 03/04/2024 through 03/19/2024 and was unsure who was covering for this patient. During interview on 03/27/2024 at 02:30 PM, the Assistant Director of Hospice and Palliative Care stated that there was no further documented evidence that any follow up was done.”

“Based on review of clinical records and interviews with staff for eight (8) of twenty- seven (27) clinical records (Patients #: 1, 6, 18, 20, 22, 23, 25, and 26), 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 ensure services were provided in accordance with the plan of care as evidenced by the following: Patient #20 – This 83-year-old patient, residing in a skilled nursing facility, with a terminal diagnosis of a right intertrochanteric hip fracture, complicated by limited mobility and pain was admitted to the hospice on 03/05/2024. Review of the Initial Visit dated 03/05/2024 revealed the Registered Nurse documented the patient has increased fatigue, increased weakness, poor endurance and is bed/wheelchair bound. Review of the Charts/ Clinical Note dated 03/07/2024 revealed the Interdisciplinary Group approved a Physical Therapy evaluation for safe transfers due to the hip fracture. Review of the clinical record lacks documentation of a Physical Therapy evaluation being conducted or patient refusal of the evaluation. During interview on 11:57 AM, the Registered Nurse stated the Physical Therapy evaluation was ordered at the request of the skilled nursing facility. She stated the evaluation occurred, but failed to be documented in the hospice record. The hospice failed to ensure services were provided in accordance to the plan of care as evidence by: Patient #6 - This 76- year- old patient, living in a skilled nursing facility with a terminal diagnosis of senile degeneration of the brain was admitted to the agency on 02/29/2024. Review of the document titled “;Determining Terminal Status” dated 02/29/2024 revealed that the patient requested volunteer services. Review of the clinical record revealed a clinical note dated 02/29/2024 stated that “;at this time no volunteer available.” Review of the Interdisciplinary Disciple Group Meeting Notes dated 03/13/2024 and 03/20/2024 revealed that under volunteer visit frequency it was documented that “;service was not elected at this time.” During an interview on 03/27/2024 at 10:00 AM, the Manager of Family Life Services stated that “;services not elected at this time” is the default response until the role has been assigned and the agency should have used free text to chart, as they are still trying to obtain volunteer services for the patient. Patient #18 - This 66-year-old with a terminal diagnosis of follicular lymphoma grade ilia, extranodal and solid organ sites was admitted on 03/05/2024. Review of Clinical Care Note titled “;Internal Request for Additional Service” dated 03/05/2024 reveals a referral for Physical Therapy for Hoyer Lift teaching. Review of the clinical record lacks documented evidence the Physical Therapist attempted to contact the patient/caregiver or made a visit. During interview on 03/27/2024 at 09:35 AM, the Case Manager stated that the patient had been a stand and pivot transfer but has become bedbound and the Hoyer lift training is no longer needed but he failed to document that. Patient #22- This 76-year-old patient with the terminal diagnosis of metastatic left lung cancer was admitted to the hospice on 03/05/2024 and expired on 03/14/2024. This patient was listed as an active patient when the surveyor requested the active patient roster on 03/18/2024. Review of the Physicians Orders/ Plan of Care from 03/05/2024 to 06/02/2024 revealed the order for home health aide services two (2) to five (5) times a week, for thirteen (13) weeks, thirty (30) minutes to one (1) hour and thirty (30) minutes duration. Review of the clinical record from 03/05/2024 to 03/20/2024 revealed the home health aide visited the patient on 03/07/2024, 03/11/2024, 03/12/2024, 03/13/2024, 03/13/2024, and 03/14/2024. There is a lack of documented evidence of two home health aide visits the week of 03/05/2024 as ordered. The hospice failed ensure services are provided in accordance with the Plan of Care. During interview on 03/27/2024 at 04:07 PM, the Assistant Director of Hospice and Palliative Care stated that only one home health aide visit was made the week of 03/05/2024, and the doctor was not notified of the missed visit. Patient #23 This 97-year-old patient, residing in a skilled nursing facility, with a terminal diagnosis of alzheimers disease with late onset was admitted to the hospice on 03/03/2024. Review of the Physicians Orders/Plan of Care from 03/03/2024 to 05/31/2024 revealed the order for home health services two (2) to five (5) times a week, for thirteen (13) weeks, thirty (30) minutes to one (1) hour and thirty (30) minutes duration. Review of the clinical record from 03/03/2024 to 03/27/2024 revealed the home health aide visited the patient on 03/05/2024, 03/11/2024, 03/12/2024, 03/13/2024, 03/14/2024, 03/15/2024, and 03/19/2024. There is a lack of documented evidence of two home health visits for the week of 03/03/2024 as ordered. The hospice failed to ensure services are provided in accordance with the Plan of Care. During an interview on 03/27/2024 at 03:53 PM, the Clinical Regulatory Compliance Specialist stated there was only one home health aide visit the week of 03/05/2024, and the doctor was not notified. Patient #26 This 87-year-old patient, residing in a skilled nursing facility, with a terminal diagnosis of dysphagia, pharyngoesophageal phase was admitted to the hospice on 03/04/2024. Review of the document titled “;Determining Terminal Status” dated 03/04/2024 revealed that the patient requested volunteer services. Review of the clinical record revealed a clinical note dated 03/04/2024 stated that “;at this time no volunteer available.” Review of the Interdisciplinary Disciple Group Meeting Notes dated 03/05/2024 and 03/19/2024 revealed that under volunteer visit frequency it was documented that “;service not elected at this time.” During an interview on 03/27/2024 at 10:00 AM, the Manager of Family Life Services stated that “;services not elected at this time” is the default response until the role has been assigned and the agency should have used free text to chart, as they are still trying to obtain volunteer services for the patient. The hospice failed to ensure services were provided in accordance to the plan of care as evidence by the following: Patient #25 – This 87-year-old patient with the terminal diagnosis of malignant neoplasm of body of pancreas was admitted to the hospice on 02/14/2024. Review of the Physicians Order/Plan of Care dated 02/14/2024 revealed the order for skilled nursing one (1) to three (3) times a week for thirteen (13) weeks. Review of the clinical record for the week from 02/25/2023 to 03/02/2024 lacks documented evidence of skilled nursing visits for the identified period as ordered. During interview on 03/26/2024 at 10:26 AM, the Clinical Regulatory Compliance Specialist stated she does not have an explanation as to why a skilled nursing visit was not made.”

“Based on review of clinical records and interviews with staff, for one (1) of twenty-seven (27) patients (Patient #9), the hospice 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 ensure appropriate education and training was provided to patients and/or caregivers as evidenced by the following: Patient #9 – This 100-year-old patient with a terminal diagnosis of gastrointestinal bleed was admitted to the hospice on 04/20/2023. Review of the Physicians Orders/ Plan of Care from 04/20/2023 to 07/18/2023 revealed the following orders: - Oxygen 2 to 4 liters continuously by nasal cannula; and - Morphine Sulfate by mouth solution 20 milligram/milliliter, 0.25 to 0.5 milliliter every hour as needed for pain or dyspnea. May also be given sublingually. Give 0.25 milliliter for mild to moderate pain or dyspnea, 0.5 milliliter for moderate to severe pain or dyspnea. Review of the Routine Visit dated 04/22/2023 revealed the Registered Nurse documented the patient has dyspnea when walking ten (10) feet, Oxygen is being used at 2 liters continuous and instructed on Oxygen use and breathing distress management. The documentation lacks instruction on titrating the Oxygen from 2 to 4 liters as needed or implementing the use of Morphine to ease dyspnea. During interview on 03/27/2024 at 11:38 AM, the Registered Nurse stated she instructed the patient and caregiver on taking medication to help the dypsnea but failed to document this.”

“Based on review of clinical records and interviews with staff for fourteen (14) of twenty-seven (27) patients (Patient #’s: 1, 2, 5, 7, 8, 9,16, 17, 18, 19, 20, 22, 23 and 27), 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 ensure plans of care are individualized, kept current and reflect the patient’s needs has the potential for unmet patient needs and health status to be compromised, resulting in poor quality of care. Patient #2 – This 89-year-old patient, residing in the hospice inpatient unit, with a terminal diagnosis of severe esophagitis with a partial obstruction was admitted to the hospice on 03/15/2024. Review of the Physicians Orders/ Plan of Care from 03/15/2024 to 06/12/2024 revealed the patient is ordered to take the following medications: - Metamucil Clear and Natural by mouth powder one (1) tablespoon daily; - Miralax by mouth powder 17 gram/scoop, 17 grams daily; - Coumadin by mouth tablet 2.5 milligram, three (3) tabs every evening; - Hydrocodone-Acetaminophen by mouth tablet 7.5- 325 milligram, one (1) tab every four (4) hours; - Buspirone HCL by mouth tablet 10 milligram three times daily; - Doxycycline Hyclate by mouth capsule 50 milligram; - Latanoprost Ophthalmic Solution 0.005 percent one (1) drop daily to each eye; - Synthroid by mouth tablet 50 microgram, one (1) tab daily; - Metronidazole external 1 percent application topically to face rash as directed; - Multivitamins by mouth tablet, one (1) tab daily; - Simvastatin by mouth tablet 20 milligram, one (1) tab every evening; - APAP (Acetaminophen) by mouth tablet 325 milligram, two (2) tabs three times a day do not take with Hydrocodone with Acetaminophen); and - Lasix by mouth tablet 20 milligram, one (1) tablet daily. Review of the Hospice Care Center- Admitting Orders revealed the patient is ordered to take: Dulcolax, Refresh Plus eye drops, Acetaminophen suppository, Robinul, Hydromorphone, Lorazepam and Haloperidol. The Admitting Orders do not include the Physicians Orders/ Plan of Care medication orders from 03/15/2024 to 06/12/2024. During interview on 03/26/2024 at 09:25 AM, the Assistant Director of Hospice and Palliative Care stated the identified Physicians Orders/ Plan of Care included medications that were never discontinued from a previous admission to the certified home health agency and should not have been included as active hospice orders. Patient #7 – This 80-year- old patient, residing in a skilled nursing facility, with a terminal diagnosis of senile degeneration of the brain was admitted to the hospice on 01/09/2024. Review of the Skilled Nursing Facility Treatment Administration Record from 01/01/2024 to 01/31/2024 revealed the patient is ordered to wear compression stockings daily, applied in the morning and removed at bedtime. Review of the Skilled Nursing Facility Home Health Aide Care Plan dated 01/09/2024 revealed the hospice aide is assigned the task of applying thromboembolism-deterrent (TED) stockings every morning and removing them every evening. Review of the Physicians Orders/ Plan of Care from 01/09/2024 to 04/07/2024 lack documentation of orders for the use of thromboembolism-deterrent stockings. During interview on 03/27/2024 at 10:23 AM, the Registered Nurse stated she failed to include the orders for the identified compression stockings on the plan of care. Patient #9 – This 100-year-old patient with a terminal diagnosis of gastrointestinal bleed was admitted to the hospice on 04/20/2023. A.) Review of the Physicians Orders/ Plan of Care from 04/20/2023 to 07/18/2024 revealed the following orders: - Acetaminophen by mouth tablet 325 milligrams, two (2) tablets every six (6) hours as needed for mild pain and fever; and Acetaminophen Rectal Suppository 650 milligrams, one (1) suppository every four (4) hours as needed for pain or fever. Maximum daily dose 3000 milligrams per rectum. The Physicians Orders/ Plan of Care lacks the maximum daily dose of Acetaminophen from all sources the patient may receive. Review of Acetaminophen (Tylenol) manufacturers guidelines revealed the maximum daily dose of Acetaminophen (Tylenol) is 4,000 mg in twenty-four (24) hours. Based on the prescribed dosage, if the patient was administered the Acetaminophen (Tylenol) as ordered, she could have received 5,600 milligrams in twenty-four (24) hours (1,600 milligrams above the maximum daily dose). During interview on 03/27/2024 at 11:11 AM, the Registered Nurse stated she failed to include the maximum daily dosage of the Acetaminophen on the plan of care orders. B.) Review of the Initial Hospice Visit dated 04/20/2023 revealed the Registered Nurse documented the patient has three (3) plus pitting edema to the left and right lower extremity. Additionally, the Registered Nurse re-ordered medigrip tubular compression bandages for the patient. Review of the Physicians Orders/ Plan of Care from 04/20/2023 to 07/18/2023 lacks order for the use of medigrip tubular compression bandages. During interview on 03/27/2024 at 11:15 AM, the Registered Nurse stated she failed to order the medigrip on the plan of care orders. Patient #20 – This 83-year-old patient, residing in a skilled nursing facility, with a terminal diagnosis of a right intertrochanteric hip fracture, complicated by limited mobility and pain was admitted to the hospice on 03/05/2024. Review of the Physicians Orders/ Plan of Care from 03/05/2024 to 06/02/2024 revealed the following medication orders: - Acetaminophen by mouth liquid 160 milligram/5 milliliter, 650 milligram four (4) times a day by mouth; and - Acetaminophen rectal suppository 650 milligram, one (1) suppository every four (4) hours rectal as needed for pain/fever. The orders lack the maximum daily dosage of Acetaminophen the patient can take from all sources. Review of Acetaminophen (Tylenol) manufacturers guidelines revealed the maximum daily dose of Acetaminophen (Tylenol) is 4,000 mg in twenty-four (24) hours. Based on the prescribed dosage, if the patient was administered the Acetaminophen (Tylenol) as ordered, she could have received 6,500 milligrams in twenty-four (24) hours (2,500 milligrams above the maximum daily dose). During interview on 03/26/2024 at 02:13 PM, the Registered Nurse stated the hospice does not specify a maximum daily dosage of Acetaminophen on orders as they follow a comfort approach to care. The hospice failed to develop individualized plans of care as evidenced by the following: Patient #17 – This 67-year-old with a terminal diagnosis of malignant neoplasm of unspecified part of left bronchus of lung was admitted to the agency on 03/05/2024. Review of the Physicians Orders/ Plan of Care from 03/05/2024 to 06/02/2024 revealed a medication order for Aspercreme Arthritis Pain External 1% 1 (one) Application BID (two times a day) External. The Physicians Orders/ Plan of Care lacks documentation of the placement of the Asperceme. During interview on 03/27/2024 at 11:33 AM, the Registered Nurse stated that the order should state where to apply the medication. Patient #18 - This 66-year-old with a terminal diagnosis of follicular lymphoma grade ilia, extranodal and solid organ sites was admitted on 03/05/2024. Review of Initial Visit dated 03/05/2024 revealed the following medical history: gastro-esophageal reflux disease and hypothyroidism. Review of the Physicians Orders/ Plan of Care from 03/05/2024 to 06/02/2024 reveals the patient is ordered to take the following medications: -Levothyroxine Sodium by mouth tablet 200 microgram everyday by mouth; -Levothyroxine Sodium by mouth tablet 25 microgram 0.5 tablet everyday by mouth; -Omeprazole by mouth capsule delayed release 40 milligrams everyday by mouth. Review of the Physicians Orders/ Plan of Care lacks diagnoses of gastro-esophageal reflux disease and hypothyroid. During interview on 03/27/2024 at 01:16 PM, the Director of Operational Excellence stated the Certification of Terminal Illness note from the physician is used to add the terminal diagnosis and co-related diagnoses onto the Physicians Orders/ Plan of Care. The Director of Operational Excellence further stated they were trained that adding non- related diagnoses was at the discretion of the nurse and did not know diagnoses related to ordered medications should be included. Patient #27 – This 82-year-old patient with the terminal diagnosis of malignant neoplasm of trigone of bladder was admitted to the hospice on 02/11/2024. Review of the Skilled Nurse Routine Note dated 03/15/2024 revealed the Skilled Nurse documented “;instructed on clean/intermittent catheterization care, Indwelling foley Catheterization/ care, UTI (urinary tract infection) prevention”. Review of the Physicians Order/Plan of Care for certification period from 02/11/2024 to 05/10/2024 lacks an order for indwelling foley catheterization care. During interview on 03/26/2024 at 01:05 PM, the Registered Nurse stated there is no order for the indwelling foley catheterization care, as the patient does not have an indwelling catheter. She added that this was an error in documentation. The hospice failed to develop individualized plans of care as evidenced by the following: Patient #1- This 71-year-old patient with the terminal diagnosis of acute kidney failure, unspecified was admitted to the hospice on 03/05/2024. Review of the Physicians Orders/ Plan of Care from 03/05/2024 to 06/02/2024 included the following medication orders: Haloperidol Lactate Injection Solution 5 milligrams/ milliliter, 2 milligrams at bedtime, injection; Glycopyrrolate Injection Solution 4 milligrams/ 20 milliliters, 4 milligrams every 8 hours, injection as needed for nausea/ vomiting; Haloperidol Lactate Injection Solution 5 milligrams/ milliliter, 1 milligram every 4 hours, injection as needed for agitation; Hydromorphone Hydrochloride Injection Solution 1 milligrams/ milliliter, 1 milligram every 3 hours, injection as needed for pain, respiratory distress. The ordered medications lack a route of administration. During interview on 03/27/2024 at 03:20 PM, the Registered nurse stated that the route for the ordered medications was not documented on the Physicians Orders/ Plan of Care. Patient #19- This 85-year-old patient with the terminal diagnosis of senile degeneration of the brain was admitted to the hospice on 02/29/2024. Review of Initial Visit dated 02/29/2024 revealed the following Medical History: anxiety, depression, respiratory failure, gastro-esophageal reflux disease, chronic obstructive pulmonary disease, and insomnia. Review of the Physicians Orders/ Plan of Care from 03/05/2024 to 06/02/2024 lacked documented evidence of the following diagnoses: depression, respiratory failure, and gastro-esophageal reflux disease. During interview on 03/27/2024 at 01:13 PM, the Director of Operational Excellence stated the Certification of Terminal Illness note from the physician is used to add the terminal diagnosis and co-related diagnoses onto the Physicians Orders/ Plan of Care. The Director of Operational Excellence further stated they were trained that adding non- related diagnoses was at the discretion of the nurse and did not know diagnoses related to ordered medications should be included. Patient #22- This 76-year-old patient with the terminal diagnosis of metastatic left lung cancer was admitted to the hospice on 03/05/2024 and expired on 03/14/2024. This patient was listed as an active patient when the surveyor requested the active patient roster on 03/18/2024. Review of Initial Visit dated 03/05/2024 revealed the following Medical History: Secondary malignant neoplasm of brain, secondary malignant neoplasm of liver and intrahepatic bile duct, secondary malignant neoplasm of adrenal gland, epilepsy without status epilepticus, atherosclerotic heart disease of native coronary artery without angina pectoris, presence of aortocoronary bypass graft, idiopathic aseptic necrosis of left femur, chronic obstructive pulmonary disease, essential hypertension, history of pulmonary embolism, history of radiation, cerebral edema, tinea unguium, gastro-esophageal reflux disease, constipation and abnormalities of gait/ mobility. Review of the Physicians Orders/ Plan of Care from 03/05/2024 to 06/02/2024 lacked documented evidence of the following diagnoses: atherosclerotic heart disease of native coronary artery without angina pectoris, presence of aortocoronary bypass graft, idiopathic aseptic necrosis of left femur, chronic obstructive pulmonary disease, essential hypertension, history of radiation, cerebral edema, tinea unguium, gastro-esophageal reflux disease, constipation, and abnormalities of gait/ mobility. During interview on 03/27/2024 at 01:13 PM, the Director of Operational Excellence stated the Certification of Terminal Illness note from the physician is used to add the terminal diagnosis and co-related diagnoses onto the Physicians Orders/ Plan of Care. The Director of Operational Excellence further stated they were trained that adding non- related diagnoses was at the discretion of the nurse and did not know diagnoses related to ordered medications should be included. Patient #5- This 96-year-old patient, residing in a skilled nursing facility, with a terminal diagnosis of senile degeneration of the brain was admitted to hospice on 03/05/2024. A.) Review of the Physicians Orders/Plan of Care from 03/05/2024 to 06/02/2024 revealed an order to insert 16 French 2-way foley with 5 cubic centimeters balloon, instilled with 10 cubic centimeter normal saline as needed for urinary retention/incontinence/comfort. Change every four to six weeks and as needed to maintain patency 16 French, 10 cubic centimeters balloon. The order for 16 French 2-way catheter lacks an order for irrigation to maintain patency as needed. The order for catheter care is incomplete. During an interview on 03/27/2024 at 10:41 AM, the Assistant Director of Hospice and Palliative care stated there should be an order to irrigate the catheter to maintain patency as needed and there is not. B) Review of the Initial Visit dated 03/05/2024 reveled foley details: Foley size 16 French, balloon size/amount water instilled: 10 milliliters, date last changed 02/29/2024. Review of the Physicians Orders/Plan of Care from 03/05/2024 to 06/02/2024 lacks documentation for patients need of catheter and catheter supplies. During an interview on 03/26/2024 at 10:32 AM, the Director of Hospice and Palliative Care stated catheter and catheter supplies are not included on the Physicians Orders/Plan of Care. C.) Review of the Physicians Orders/Plan of Care from 03/05/2024 to 06/02/2024 revealed an order for the following: - insert 16 French 2-way foley with 5 cubic centimeters balloon, instilled with 10 cubic centimeter normal saline as needed for urinary retention/incontinence/comfort. - change every four to six weeks and as needed to maintain patency 16 French, 10 cubic centimeters balloon. The order for the catheter balloon size is inconsistent on the plan of care. During an interview on 03/27/2024 at 10:33 AM, the Registered Nurse stated the catheter orders cannot be customized. D.) Review of the Physicians Orders/Plan of Care from 03/05/2024 to 06/02/2024 revealed an order for Melatonin by mouth tablet 3 milligrams one alternating dose at bedtime by mouth. The medication order lacks a frequency. During an interview on 03/27/2024 at 10:44 AM, the Registered Nurse stated the medication should be taken daily and is not alternating. E.) Review of the Physicians Orders/Plan of Care from 03/05/2024 to 06/02/2024 revealed an order for Blu emu topical gel with emu oil one application as needed for arthritis. The medication order lacks an amount, location, and frequency to apply. During an interview on 03/27/2024 at 10:46 AM, the Registered Nurse stated the order should include amount, location, and frequency to apply and does not. F.) Review of the Physicians Orders/Plan of Care from 03/05/2024 to 06/02/2024 revealed an order for Acetaminophen by mouth tablet 325 milligram two tablets every four hours by mouth as needed for pain/fever. The medication order lacks instructions for maximum daily dose. During an interview on 03/27/2024 at 10:49 AM, the Registered Nurse stated the maximum daily dose should be included on the order and is not. G.) Review of the Physicians Orders/Plan of Care from 03/05/2024 to 06/02/2024 revealed an order for Polyethylene glycol 3350 by mouth powder 17 gram/scoop 17 gram every day by mouth as needed for constipation. The medication order lacks instructions to mix powder with fluid. During an interview on 03/27/2024 at 10:50 AM, the Registered Nurse stated the instructions to mix powder in water should be included and are not. Patient #8- This 93-year-old patient with a terminal diagnosis of multiple sclerosis was admitted to the Hospice on 12/16/2023. A.) Review of the Physicians Orders/Plan of Care from 12/16/2023 to 03/14/2024 revealed an order to insert 16 French 2-way foley with 5 cubic centimeters balloon, instilled with 10 cubic centimeter normal saline as needed for urinary retention/incontinence/comfort. Change every four to six weeks and as needed to maintain patency. Number 16 French/10 milliliter foley catheter placed 12/16/2023. The order for 16 French 2-way catheter lacks an order for irrigation to maintain patency as needed. The order for catheter care is incomplete. During an interview on 03/26/2024 at 10:41 AM, the Registered Nurse stated there should be an order to irrigate the catheter to maintain patency as needed and there is not. B) Review of the Initial Visit dated 12/16/2023 reveled foley details: Foley size 16 French, balloon size/amount water instilled: 10 milliliters, date last changed 12/16/2023. Review of the Physicians Orders/Plan of Care from 12/16/2023 to 03/14/2024 lacks documentation for patients need of catheter and catheter supplies. During an interview on 03/26/2024 at 10:40 AM, the Registered Nurse stated all supplies are in the home and should be included in durable medical equipment and supplies on Physicians Orders/Plan of and are not. C.) Review of the Physicians Orders/Plan of Care from 12/16/2023 to 03/14/2024 revealed an order for Metamucil by mouth powder 46.57% 10 milliliter everyday by mouth. The plan of care lacks instructions to mix powder in fluid. During an interview on 03/26/2024 at 11:00 AM, the Registered Nurse stated the patient was taking and instructions to mix powder with fluid should have been included and was not. D.) Review of the Hospice Interdisciplinary Group Review dated 01/16/2024 revealed an order for Aleve 220 milligram one tablet every day. The order lacks a route to administer medication. During an interview on 03/27/2024 at 09:45 AM, the Assistant Director of Hospice and Palliative Care stated the medication should include a route to administer and does not. E.) Review of the Hospice Interdisciplinary Group Review dated 01/16/2024 revealed an order for Vitamin D 3 25 microgram (1,000 unit) one tablet every day. The order lacks a route to administer medication. During an interview on 03/27/2024 at 09:43 AM, the Registered Nurse stated the medication should include a route to administer and does not. Patient # 23 This 97-year-old patient, residing in a skilled nursing facility, with a terminal diagnosis of alzheimers disease with late onset was admitted to the hospice on 03/03/2024. A.) Review of Initial Visit on 03/03/2024 revealed the Registered Nurse documented the following: - diabetes detail: document diabetes; - symptoms: well controlled; - insulin/oral agents: insulin injection; - appearance of feet: right and left clean; and blood test frequency: before each meal; and - gastrointestinal assessment: incontinence. Review of Physicians Orders/Plan of care from 03/03/2024 to 05/31/2024 lacks an order for diabetic testing supplies. During an interview on 03/27/2024 at 01:21 PM, the Assistant Director of Hospice and Palliative Care stated diabetic testing supplies were not included on the physician orders. B.) Review of the Initial Visit on 03/03/2024 revealed the Registered Nurse documented voiding method: incontinent: briefs. Review of the Physicians Orders/Plan of Care from 03/03/2024 to 05/31/2024 lacks an order for incontinence supplies. During an interview on 03/27/2024 at 01:29 PM, the Registered Nurse stated incontinence briefs were not included on the physicians orders. C.) Review of the Physicians Orders/Plan of Care from 03/03/2024 to 05/31/2024 revealed an order for Diclofenac sodium external 1% one application four times a day external topical left shoulder. The medication order lacks an amount to apply. During an interview on 03/27/2024 at 01:24 PM, the Registered Nurse stated the order should include amount to apply and does not. Patient #16- This 95-year-old patient with a terminal diagnosis of alzheimers disease was admitted to the hospice on 03/05/2024. Review of Initial Visit on 03/05/2024 revealed the registered nurse documented the following: - voiding method: incontinent total. -gastrointestinal assessment: incontinence. Review of Physicians Orders/Plan of care from 03/05/2024 to 06/02/2024 lacks an order for incontinence supplies. During an interview on 03/26/2024 at 12:01 PM, the Registered Nurse stated patient uses incontinence supplies, which, were not included on the physician orders.”

“Based on review of clinical records and interviews with staff, the hospice failed to ensure in two (2) of twenty-seven (27) clinical records (Patient #’s: 3, and 16), that care and services are provided in accordance with the Plan of Care (POC). Failure to provide care in accordance with the established plan of care has the potential to result in inappropriate care, unmet patient needs and negative patient outcomes. Patient #16- This 95-year-old patient with a terminal diagnosis of alzheimers disease was admitted to the hospice on 03/05/2024. Review of Routine Visit on 03/11/2024 revealed the Registered Nurse documented pain management: Tylenol at 02:30 pm, pain control is acceptable. Review of the clinical record lacks an order for Tylenol. During an interview on 03/26/2024 at 03:17 PM, the Registered Nurse stated there should have been an order for Tylenol and there is not. The hospice failed to ensure that care and services are provided in accordance with the Plan of Care as evidenced by: Patient #3 – This 87-year-old patient residing in the hospice inpatient unit, with a terminal diagnosis of malignant neoplasm of unspecified site of left female breast was admitted to the hospice on 11/22/2023. Review of the Routine Visit dated 11/28/2023 revealed the Registered Nurse documented that the patient takes Tylenol and daughter uses voltaren rub when her knees ache. Review of the clinical record lacks an order for the voltaren rub. During interview on 03/27/2024 at 11:41 AM, the Registered Nurse stated she did not obtain an order for the identified voltaren rub being used but should have.”

“Based on review of clinical records and interviews with staff, for three (3) of twenty- seven (27) clinical records (Patient #’s: 1, 10 and 19), the hospice failed to ensure ongoing sharing of information between all disciplines providing care. Failure to ensure the ongoing sharing of information has the potential for unmet patient needs. The hospice failed to ensure information is shared between all disciplines providing care as evidenced by the following: Patient #10 – This 58-year-old patient with a terminal diagnosis of end stage chronic obstructive pulmonary disease was admitted to the hospice on 10/04/2023. Review of the Routine Visit conducted by the Social Worker dated 10/05/2023 revealed the Social Worker documented the patient is not feeling well with an oxygen saturation of 63 currently using 10 liters of oxygen over the tracheostomy. Congestion is heard in the patients throat and coughing is occurring. The Social Worker contacted the hospice Nurse who spoke to the patient and spouse over the telephone speaker. The hospice Nurse instructed the patient to attempt suctioning the tracheostomy and instructed when the comfort kit arrives in home, to read instructions and take Morphine and Lorazepam. Additionally, the hospice Nurse instructed when the replacement Oxygen concentrator is delivered to ensure to use the humidification attached to it. Review of the clinical record lacks documented evidence the attending physician and Interdisciplinary Group were notified regarding the patients change in status. During interview on 03/26/2024 at 12:54 PM, the Registered Nurse stated she did not notify the attending physician or the Interdisciplinary Group of the patients status changes. Patient #1- This 71-year-old patient with the terminal diagnosis of acute kidney failure, unspecified was admitted to the hospice on 03/05/2024. Review of Inpatient Unit Comprehensive Daily Assessment dated 03/09/2024, revealed the Registered Nurse documented the following: Gastrointestinal: Last Bowel Movement: 03/01/2024, Gastrointestinal assessment: No problems identified, Comments: has Dulcolax suppository around the clock every three (3) days, Details: Not applicable. Review of Inpatient Unit Comprehensive Daily Assessment dated 03/108/2024, revealed the Registered Nurse documented the following: Gastrointestinal: Last Bowel Movement: 03/01/2024, Gastrointestinal assessment: Constipation, Comments: patient to have Dulcolax suppository given today. Patient has been nothing by mouth, Details: Not applicable. Review of the clinical record from 03/09/2024 to 03/19/2024 lacks documented evidence of any communication between the Hospice Registered Nurse, the hospital nurse, or the physician regarding the patients lack of a bowel movement for nine (9) days. During interview on 03/26/2024 at 10:12 AM, the Registered Nurse stated that the patients abdomen was soft and non-tender when assessed and the patient had a scheduled medication. The Registered Nurse further stated that if the medication was not administered, it would be documented so it must have been given and no reported results on the Medication Administration Record and the Registered Nurse did not speak to the hospital nurse or the physician since the patient was receiving Dulcolax and the medication was due to be given on 03/10/2024. During interview on 03/27/2024 at 03:09 PM, a different Registered Nurse provided documented evidence that the patients family refused the patients scheduled doses of Dulcolax suppository on 03/04/2024, 03/07/2024, and 03/10/2024. This information was provided to the Hospice Registered Nurse verbally from the hospital staff and was in fact documented on the Medication Administration Record that the patients family declined the medication. Review of the patients Administration Information for Dulcolax Suppository provided to surveyor on 03/27/2024 at 03:18 PM confirmed that the patients family refused the medication on 03/04/2024, 03/07/2024 and 03/10/2024. Patient #19- This 85-year-old patient with the terminal diagnosis of senile degeneration of the brain was admitted to the hospice on 02/29/2024. Review of the Charts/ Clinical Notes dated 03/06/2024, revealed the Nurse Practitioner documented that a message was received from the On-call Registered Nurse regarding the patients continued overnight agitation. Review of the clinical record from 03/06/2024 to 03/21/2024 lacks documented evidence that the On-call Registered Nurse documented a call from the patients caregiver regarding the patients continued overnight agitation or any follow up with the Nurse Practitioner. During interview on 03/28/2024 at 09:12 AM, the (On-call) Registered Nurse stated, “;Im relatively new so that was my first on-call call, and I should have written a note, but I forgot.””

“Based on the review of the bereavement records, agency policy and procedure, and staff interview, for one (1) of four (4) bereavement patients (Patient #14) the agency failed to follow its bereavement program as outlined by the hospice bereavement policy and procedure. Failure of the hospice to implement individualized bereavement plans has the potential for unmet needs of the bereaved hospice patient’s families/caregivers. The hospice failed to follow its bereavement policy program as evidence by: Review of the agency’s policy entitled “Bereavement Counseling and Services” last approved 11/2023 revealed: “Procedure: III. The Interdisciplinary Group utilizes the Bereavement Assessment and medical record to develop an appropriate Bereavement Care Plan to meet each individuals identified risks and needs. B. A condolence card signed by the Interdisciplinary Group team will be sent to the family following the patients death. IV. All bereaved individuals will receive the following: A. A package will be sent one month after the death that includes information about the grieving process, the availability of bereavement counseling, contact information, and an updated list of support groups. “; Patient #14 - This 84-year-old with a terminal diagnosis of senile degeneration of the brain was admitted to the agency on 11/30/2022 and expired on 01/24/2023. Review of the patients bereavement record lacks documented evidence of a condolence card signed by the Interdisciplinary Group following the death or of a package being sent one month after. During an interview on 03/27/2024 at 03:39 PM, the Assistant Director of Hospice and Palliative Care stated a condolence card and package should have been sent to the bereaved.”

“Based on review of clinical records and interviews with staff, for three (3) of twelve (12) patients receiving aide services (Patient #s: 7, 9 and 20), the hospice failed to ensure the hospice aide plan of care is complete and individualized to the patient’s needs. Failure to ensure the aide plan of care is complete and individualized has the potential for the patient to receive inappropriate care. The hospice failed to ensure aide plans of care are complete and individualized to the patients needs as evidenced by the following: Patient #7 – This 80-year- old patient, residing in a skilled nursing facility, with a terminal diagnosis of senile degeneration of the brain was admitted to the hospice on 01/09/2024. Review of the Physicians Orders/ Plan of Care from 01/09/2024 to 04/07/2024 revealed an order for Home Health Aide two (2) to five (5) times weekly for thirteen (13) weeks, duration: thirty (30) minutes to one (1) hour and thirty (30) minutes. Review of the Skilled Nursing Facility Home Health Aide Care Plan revealed the hospice aide is assigned the following tasks: 1. Bath- complete, partial, bed, shower, sponge every day and evening shift; 2. Skin care- wash hands/feet, apply lotion every day and evening shift; 3. Hair care- shampoo, comb/brush every day and evening shift; 4. Oral care- brush teeth, oral swabs every day and evening shift; 5. Nail care- clean every day, file as needed every day and evening shift; 6. Assist with elimination- check for incontinence every one (1) to two (2) hours on day and evening shift; 7. Turn and reposition client every one (1) to two (2) hours as needed on day and evening shift; 8. Assist with dressing every day and evening shift; 9. Ambulate, one assist stand/pivot every day and evening shift; 10. Transfer, one assist pivot every day and evening shift; 12. Assist with meals/feeding according to schedule one (1) assist, needs encouragement every day and evening shift; 13. Assist with equipment- Teds (thromboembolism-deterrent stockings) on in morning and off in evening- every day and evening shift; and 16. Light housekeeping- tidy room, change soiled linens/ make bed as needed every day and evening shift. Review of the Aide Time and Activity Sheet printed from the electronic medical record revealed from 02/15/2024 to 03/16/2024 the aide is assigned the following tasks: - Bathing activity assistance (task 1) – one assist every shift; - Personal Care and hygiene (tasks 2-5)- total assist every shift; - Assist with bowel/bladder hygiene (task 6)- incontinent, every shift; - Turn and position every one (1) to two (2) hours, unless specified (task 7)- one (1) assist every shift; - Assist with dressing, full assist (task 8) every shift; - Transfer/ambulation assist (tasks 9 and 10), one assist stand/pivot every shift; - Meals- prepare/serve/feed regular mechanical soft, one (1) assist (task 12) every shift; and - Light housekeeping/laundry for client used areas only (tasks 16 to 17) tidy room every shift. The electronic medical record Aide Time and Activity Sheet fails to assign the aides the task of applying thromboembolism-deterrent stockings every morning and removing stockings every evening. Patient #9 – This 100-year-old patient with a terminal diagnosis of gastrointestinal bleed was admitted to the hospice on 04/20/2023. Review of the Physicians Orders/ Plan of Care from 04/20/2023 to 07/18/2023 revealed an order for Home Health Aide three (3) to five (5) times weekly for thirteen (13) weeks, duration one (1) hour thirty (30) minutes to two (2) hours. Review of the Aide Care Plan dated 04/20/2023 revealed the aide is assigned the following tasks: 1. Bath- complete, bed, shower or sponge with shower chair three to five times weekly; 2. Skin care- wash hands/feet, incontinence, apply lotion three to five times weekly; 3. Hair care- shampoo, comb/brush, offer three to five times weekly; 4. Oral care- brush teeth three to five times weekly; 5. Nail care- clean and file three to five times weekly; 6. Assist with elimination- toilet or commode three to five times weekly; 7. Turn/ position every two (2) hours while awake, three to five times weekly; 8. Partial assist with dressing three to five times weekly; 9. Ambulation assist- stand/pivot three to five times weekly; 10. Transfer- assist pivot transfer three to five times weekly; 11. Range of motion- passive three to five times weekly; 12. Assist with meals/feeding- offer foods and fluids three to five times weekly; 13. Assist with equipment- Oxygen three to five times weekly; 14. Temperature, pulse, respirations (TPR) offer three to five times weekly; 15. Medication reminder three to five times weekly; and 18. Reality orientation three to five times weekly. Review of the Aide Time and Activity Sheet printed from the electronic medical record revealed from 04/21/2023 to 04/25/2023 the aide is assigned the following tasks: - Bathing activity assistance (task 1) every shift; - Personal care and hygiene (tasks two (2) through five (5)) every shift; - Assist with bowel/bladder hygiene (task 6) every shift; - Turn/ position every one (1) to two (2) hours, unless specified (task 7) every shift; - Dressing- full/ partial assist (task 8) every shift; - Transfer/ ambulation assist (tasks 9 and 10)- stand pivot one assist to stand every shift; - Meals- prepare/ serve/ feed (task 12)- offer food and fluids every shift; and - Other equipment to assist with (task 13)- Oxygen concentrator every shift. The electronic medical record Aide Time and Activity Sheet fails to assign the aides the following tasks three (3) to five (5) times weekly: passive range of motion, offer to obtain temperature, pulse and respirations, medication reminders and reality orientation. During interview on 03/27/2024 at 01:42 PM, the Clinical Regulatory Compliance Specialist acknowledged the identified paper and electronic aide care plans are inconsistent in the tasks they each assign and would look for additional documentation to clarify. No further documentation was provided. Patient #20 – This 83-year-old patient, residing in a skilled nursing facility, with a terminal diagnosis of a right intertrochanteric hip fracture, complicated by limited mobility and pain was admitted to the hospice on 03/05/2024. Review of the Physicians Orders/ Plan of Care from 03/05/2024 to 06/02/2024 revealed an order for Home Health Aide two (2) to five (5) times weekly for thirteen (13) weeks, duration thirty (30) minutes to one (1) hour and thirty (30) minutes. Review of the Skilled Nursing Facility Home Health Aide Care Plan dated 03/05/2024 assigns the hospice aide the following tasks: 1. Bath- complete, bed, with one assist every day and evening shift; 2. Skin care- wash hands/ feet, incontinence, apply lotion, with one assist every day and evening shift; 3. Hair care- shampoo, comb/ brush with one assist every day and evening shift; 4. Oral care- brush teeth with one assist every day and evening shift; 5. Nail care- clean every day, file as needed with one assist every day and evening shift; 6. Assist with elimination- check for incontinence every one (1) to two (2) hours, incontinent- every day and evening shift; 7. Turn and reposition client every one (1) to two (2) hours as needed with one assist every day and evening shift; 8. Assist with dressing, full assist every day and evening shift; 9. Ambulate- non-ambulatory every day and evening shift; 10. Transfer- bed bound every day and evening shift; 12. Assist with meals/ feeding according to schedule- total feed every day and evening shift; and 16. Light housekeeping- tidy room, change soiled linens/ make bed as needed every day and evening shift. Review of the Routine Visit dated 03/18/2024 revealed the Registered Nurse documented the following: - the patient has two (2) new pressure ulcers, one (1) on the right buttocks and the second (2) on the mid back; - a new alternative pressure mattress has been ordered; and - facility staff to place pillows on either side of back when up in chair and place on left side using a wedge when in bed. Review of the clinical record lacks documentation the aide care plan was updated regarding the new pressure areas and positioning recommendations identified in the 03/18/2024 nursing assessment. During interview on 03/27/2024 at 12:16 PM, the Registered Nurse stated she verbalized the changes in skin and positioning to the hospice aide but failed to update the aide care plan.”

“Based on review of clinical records and interviews with agency staff, the agency failed to provide aide services as identified in the aide care plan for three (3) of twelve (12) patients, (Patient #’s: 4, 7, and 9), receiving hospice aide services. Failure to ensure care is provided in accordance with the aide care plan has the potential to result in incorrect care, unmet patient needs, and possible negative outcomes. The hospice failed to ensure care provided by hospice aides is in accordance with the aide care plan as evidenced by the following: Patient #4 – This 90-year-old patient, residing in an assisted living facility, with a terminal diagnosis of senile degeneration of the brain was admitted to the hospice on 03/04/2024. Review of the Physicians Orders/ Plan of Care from 03/04/2024 to 05/01/2024 revealed an order for Home Health Aide one (1) to three (3) times weekly for thirteen (13) weeks, duration one (1) to two (2) hours. Review of the Skilled Nursing Facility Home Health Aide Care Plan dated 03/04/2024 revealed the hospice aide is assigned the following tasks: 1. Bath- complete twice weekly; 2. Skin care- wash hands/ feet, incontinence, apply lotion, every shift; 3. Hair care- comb/ brush, provide cueing every shift; 4. Oral Care- brush teeth, provide cueing every shift; 5. Nail care- clean every day, file as needed every shift; 6. Assist with elimination- toilet, check for incontinence every one (1) to two (2) hours, wears depends, every shift; 8. Assist with dressing- full assist every shift; 9. Ambulate- uses walker every shift; 10. Transfer every shift; 12. Assist with meals/ feeding according to schedule, oral diet, needs encouragement every shift; 14. Weigh patient as requested every month; and 16. Light housekeeping- tidy room, change soiled linens/ make bed as needed every shift. A.) Review of the Community Home Health Time Sheet (aide documentation) revealed the following activity key: - Enter an X for each task performed, if task cannot be performed, use the following letters and the space on the bottom of the page for additional comments, if needed: C- client completed F- family/ friend completed D- declined by client. Review of the Community Home Health Time Sheet dated 03/05/2024 lacks documentation the hospice aide either offered and patient/ family declined or previously completed or the aide performed the assigned task of assistance with meals/ feeding. During interview on 03/27/2024 at 03:00 PM, the Clinical Regulatory Compliance Specialist acknowledged the aide left the assigned task blank and failed to complete the activity and time sheet as instructed. B.) Review of the Community Home Health Time Sheet dated 03/05/2024 revealed the hospice aide documented completing the task of turning and positioning the client, a task not assigned on the aide care plan. During interview on 03/27/2024 at 02:55 PM, the Clinical Regulatory Compliance Specialist acknowledged the aide documented completing a task incorrectly that was not assigned on the aide care plan. Patient #7 – This 80-year- old patient, residing in a skilled nursing facility, with a terminal diagnosis of senile degeneration of the brain was admitted to the hospice on 01/09/2024. Review of the Physicians Orders/ Plan of Care from 01/09/2024 to 04/07/2024 revealed an order for Home Health Aide two (2) to five (5) times weekly for thirteen (13) weeks, duration: thirty (30) minutes to one (1) hour and thirty (30) minutes. Review of the Skilled Nursing Facility Home Health Aide Care Plan revealed the hospice aide is assigned the following tasks: 1. Bath- complete, partial, bed, shower, sponge every day and evening shift; 2. Skin care- wash hands/feet, apply lotion every day and evening shift; 3. Hair care- shampoo, comb/brush every day and evening shift; 4. Oral care- brush teeth, oral swabs every day and evening shift; 5. Nail care- clean every day, file as needed every day and evening shift; 6. Assist with elimination- check for incontinence every one (1) to two (2) hours on day and evening shift; 7. Turn and reposition client every one (1) to two (2) hours as needed on day and evening shift; 8. Assist with dressing every day and evening shift; 9. Ambulate, one assist stand/pivot every day and evening shift; 10. Transfer, one assist pivot every day and evening shift; 12. Assist with meals/feeding according to schedule one (1) assist, needs encouragement every day and evening shift; 13. Assist with equipment- Teds (thromboembolism-deterrent stockings) on in morning and off in evening- every day and evening shift; and 16. Light housekeeping- tidy room, change soiled linens/ make bed as needed every day and evening shift. Review of the Aide Time and Activity Sheet printed from the electronic medical record for the week of 01/14/2024 to 01/20/24 and the week of 01/21/2024 to 01/27/2024 lack documentation the aide completed or the patient refused the assigned task of applying thromboembolism-deterrent stockings in the morning and removing them every evening for the following dates: 01/15/2024, 01/16/2024, 01/17/2024, 01/18/2024, 01/22/2024, 01/23/2024, 01/24/2024, 01/25/2024 and 01/26/2024. Patient #9 – This 100-year-old patient with a terminal diagnosis of gastrointestinal bleed was admitted to the hospice on 04/20/2023. Review of the Physicians Orders/ Plan of Care from 04/20/2023 to 07/18/2023 revealed an order for Home Health Aide three (3) to five (5) times weekly for thirteen (13) weeks, duration one (1) hour thirty (30) minutes to two (2) hours. Review of the Aide Care Plan dated 04/20/2023 revealed the aide is assigned the following tasks: 1. Bath- complete, bed, shower or sponge with shower chair three to five times weekly; 2. Skin care- wash hands/feet, incontinence, apply lotion three to five times weekly; 3. Hair care- shampoo, comb/brush, offer three to five times weekly; 4. Oral care- brush teeth three to five times weekly; 5. Nail care- clean and file three to five times weekly; 6. Assist with elimination- toilet or commode three to five times weekly; 7. Turn/ position every two (2) hours while awake, three to five times weekly; 8. Partial assist with dressing three to five times weekly; 9. Ambulation assist- stand/pivot three to five times weekly; 10. Transfer- assist pivot transfer three to five times weekly; 11. Range of motion- passive three to five times weekly; 12. Assist with meals/feeding- offer foods and fluids three to five times weekly; 13. Assist with equipment- Oxygen three to five times weekly; 14. Temperature, pulse, respirations (TPR) offer three to five times weekly; 15. Medication reminder three to five times weekly; and 18. Reality orientation three to five times weekly. Review of the electronic medical record Aide Time and Activity Sheets dated 04/21/2023, 04/24/2023 and 04/25/2023 lack documentation the aides completed or the patient refused the following assigned tasks: passive range of motion, offer to obtain temperature, pulse and respirations, medication reminders and reality orientation. During interview on 03/27/2024 at 01:40 PM, the Clinical Regulatory Compliance Specialist acknowledged the identified tasks were assigned on the paper aide care plan but failed to be assigned on the electronic aide activity sheet and would look for additional documentation to explain the discrepancy. No further documentation was provided.”

“Based on a review of clinical records and interview with agency staff, for eight (8) of twelve (12) patients (Patient #s: 4, 5, 7, 8, 9, 20, 22 and 23) receiving Home Health Aide services, the hospice failed to ensure that a supervisory visit was completed at the initial aide service visit to ensure the aide is oriented to the patient and the aide care plan. Failure to ensure aides are properly supervised has the potential for unmet patient needs and inadequate patient care. Patient #5- This 96-year-old patient, residing in a skilled nursing facility, with a terminal diagnosis of senile degeneration of the brain was admitted to hospice on 03/05/2024. Review of the Aide Time and Activity Sheet from 03/06/2024 to 03/14/2024 revealed the home health aides initial visit to the patient occurred on 03/06/2024. Review of the clinical record from 03/05/2024 to 03/26/2024 lacks documented evidence that the Registered Nurse completed an initial supervision visit or telephone call with the home health aide on 03/06/2024. During an interview on 03/26/2024 at 11:22 AM, the Assistant Director of Hospice and Palliative Care stated that there was no initial supervision done by the registered nurse. Patient #8- This 93-year-old patient with a terminal diagnosis of multiple sclerosis was admitted to the hospice on 12/16/2023. Review of the Aide Time and Activity Sheet from 12/17/2023 to 12/23/2023 revealed the home health aides initial visit to the patient occurred on 12/18/2024. Review of the clinical record from 12/16/2023 to 03/27/2024 lacks documented evidence that the Registered Nurse completed an initial supervision visit or telephone call with the home health aide on 12/18/2024. During an interview on 03/27/2024 at 09:52 AM, the Assistant Director of Hospice and Palliative Care stated that there was no initial supervision done by the registered nurse. Patient # 23 This 97-year-old patient, residing in a skilled nursing facility, with a terminal diagnosis of alzheimers disease with late onset was admitted to the hospice on 03/03/2024. Review of the Aide Time and Activity Sheet from 03/05/2024 to 03/19/2024 revealed the home health aides initial visit to the patient occurred on 03/05/2024. Review of the clinical record from 03/03/2024 to 03/27/2024 lacks documented evidence that the Registered Nurse completed an initial supervision visit or telephone call with the home health aide on 03/05/2024. During an interview on 03/27/2024 at 03:52 PM, the Clinical Regulatory Compliance Specialist stated that there was no initial supervision done by the registered nurse. Patient #22- This 76-year-old patient with the terminal diagnosis of metastatic left lung cancer was admitted to the hospice on 03/05/2024 and expired on 03/14/2024. This patient was listed as an active patient when the surveyor requested the active patient roster on 03/18/2024. Review of the Aide Time and Activity Sheet from 03/05/2024 to 03/19/2024 revealed the home health aides initial visit to the patient occurred on 03/07/2024. Review of the clinical record from 03/05/2024 to 03/20/2024 lacked documented evidence that the Registered Nurse completed an initial supervision visit or telephone call with the home health aide on 03/07/2024. During interview on 03/27/2024 at 04:06 PM, the Assistant Director of Hospice and Palliative Care stated that there was no initial supervision done by the registered nurse. The hospice failed to ensure aides were supervised at the initial service visit as evidenced by the following: Patient #4 – This 90-year-old patient, residing in an assisted living facility, with a terminal diagnosis of senile degeneration of the brain was admitted to the hospice on 03/04/2024. Review of the Aide Time and Activity Sheets from 03/05/2024 to 03/15/2024 revealed the initial service visit of the Home Health Aide occurred on 03/05/2024. Review of the clinical record lacks documentation the Registered Nurse completed an aide supervision for the initial aide service visit occurring on 03/05/2024. During interview on 03/27/2024 at 02:40 PM, the Registered Nurse stated she failed to perform a supervisory visit or call for the 03/05/2024 initial aide visit. Patient #7 – This 80-year- old patient, residing in a skilled nursing facility, with a terminal diagnosis of senile degeneration of the brain was admitted to the hospice on 01/09/2024. Review of the Aide Time and Activity Sheets for the week of 01/14/2024 to 01/20/2024 revealed the initial service visit of the Home Health Aide occurred on 01/15/2024. Review of the clinical record lacks documentation the Registered Nurse completed an aide supervision for the initial aide service visit occurring on 01/15/2024. During interview on 03/27/2024 at 01:47 PM, the Registered Nurse stated an aide supervision did not occur for the 01/15/2024 initial aide visit. Patient #9 – This 100-year-old patient with a terminal diagnosis of gastrointestinal bleed was admitted to the hospice on 04/20/2023. Review of the Aide Time and Activity Sheets from 04/21/2023 to 04/29/2023 revealed the initial service visit of the Home Health Aide occurred on 04/21/2023. Review of the clinical record lacks documentation the Registered Nurse completed an aide supervision for the initial aide service visit occurring on 04/21/2023. During interview on 03/27/2024 at 03:40 PM, the Assistant Director of Hospice and Palliative Care stated no supervision occurred for the initial aide visit on 04/21/2023. Patient #20 – This 83-year-old patient, residing in a skilled nursing facility, with a terminal diagnosis of a right intertrochanteric hip fracture, complicated by limited mobility and pain was admitted to the hospice on 03/05/2024. Review of the Aide Time and Activity Sheets from 03/07/2024 to 03/15/2024 revealed the initial service visit of the Home Health Aide occurred on 03/07/2024. Review of the clinical record lacks documentation the Registered Nurse completed an aide supervision for the initial aide service visit occurring on 03/07/2024. During interview on 03/27/2024 at 12:20 PM, the Registered Nurse stated being unavailable to conduct a supervision for the initial aide visit that occurred on 03/07/2024.”

“Based on review of clinical records and interview with agency staff, for three (3) of twenty-seven (27) patients (Patient #s: 1, 6, and 19) the hospice failed to ensure the clinical record is complete and contains all pertinent information, is consistent and accurately reflects the care and delivery of service to the patient. Failure to ensure clinical records are complete and contain all pertinent/ accurate information related to patient care and services has the potential to result in inadequate and inappropriate care. Home Visit Patient #6- This 76- year- old patient, living in a skilled nursing facility with a terminal diagnosis of senile degeneration of the brain was admitted to the agency on 02/29/2024. Review of the Initial Comprehensive visit dated 02/29/2024 revealed that the Register Nurse documented the patient was “;ordered to wear compression sleeves to the arms with instructions to elevate limbs.” During an observational home visit on 03/19/2024 at 01:23 PM it was observed that the patient was not wearing compression sleeves. Review of the facilities Treatment Record for 03/19/2024 lacks documented evidence of an order for compression sleeves. Review of the Physicians Orders/ Plan of Care from 02/29/2024 to 05/28/2024 lacks documentation of an order for the compression sleeves. During interview on 03/27/2024 at 11:56 AM, the Case Manager stated the patient refuses the compression sleeves and there should be further documentation to clarify. The hospice failed to ensure records were complete and contained all pertinent information related to the care and delivery of service to the patient as evidenced by the following: Patient #1- This 71-year-old patient with the terminal diagnosis of acute kidney failure, unspecified was admitted to the hospice on 03/05/2024. A. Review of Inpatient Unit Comprehensive Visit dated 03/12/2024, revealed the Registered Nurse documented under Skin/ Incision/ Wound: Site Location: Specify location: Left Heel, Type: Pressure ulcer. Review of the Charts/ Clinical Notes dated 03/12/2024 revealed the Registered Nurse documented “;... right heel has a stage one (1) measuring four and a half (4.5) centimeters by five (5) centimeters, ...” Review of the clinical record from 02/29/2024 to 03/19/2024 revealed the patient’s pressure ulcer is located on the right heel, not the left heel. During interview on 03/26/2024 at 04:02 PM, the Registered Nurse (Employee U) stated that the patient has a right heel wound. Documentation of a left heel wound was a typographical error. B. Review of the Charts/ Clinical Notes dated 03/12/2024 revealed the Registered Nurse documented “;... 0020: Patient with a facial grimace; as needed Hydromorphone 1 milligram subcutaneous administered. On reassessment patient no longer has facial grimace and appears to be resting comfortably. 0415: Patient with a furrowed brow; as needed Hydromorphone 1 milligram subcutaneous administered. On reassessment patient with relaxed facial features...” Later within the same clinical note the Registered Nurse also documented “;Around the clock/ As needed medications: Hydromorphone 1 milligram, Intravenous every four (4) hours around the clock and every one (1) hour as needed for pain, dyspnea: two (2) as needed doses administered this shift...” During interview on 03/26/2024 at 30:59 PM, the Registered Nurse (Employee U) stated, “;I definitely gave the medication intravenously and must have made an error in my notes stating subcutaneous, the subcutaneous was a typographical error.” C. Review of Inpatient Unit Comprehensive Visit dated 03/12/2024 revealed the Registered Nurse documented under Skin/ Incision/ Wound: Site Location: Specify location: Left Heel, Type: Pressure ulcer. Review of the clinical record from 02/29/2024 to 03/19/2024 revealed the patient had a right heel pressure ulcer. During interview on 03/28/2024 at 08:51 AM, the Registered Nurse (Employee WW) stated that the patient has a right buttock wound and a right heel wound, and that the documentation of a left heel wound was a typographical error. D. Review of the Charts/ Clinical Notes dated 03/12/2024 revealed the Registered Nurse documented “;...Subcutaneous medications indicated for adequate symptom control...” Later within the same clinical note the Registered Nurse also documented “;Around the clock/ As needed medications: Hydromorphone 1 milligram, Intravenous every four (4) hours around the clock and every one (1) hour as needed for pain, dyspnea: one (1) as needed dose administered this shift...” During interview on 3/28/2024 at 08:53 AM, the Registered nurse (Employee WW) stated, “;The patient has a central line, so all medications were ordered for intravenous route. Subcutaneous was a typographical error.” Patient #19- This 85-year-old patient with the terminal diagnosis of senile degeneration of the brain was admitted to the hospice on 02/29/2024. Review of the Charts/ Clinical Notes dated 03/07/2024 revealed the Registered Nurse documented that the patients primary caregiver called into triage. The Registered Nurse attempted to call the primary caregiver back but there was no answer, the Registered Nurse left a voicemail to call 21-1000 regarding questions/ concerns. During interview on 03/28/2024 at 09:30 AM, the Clinical Regulatory Compliance Specialist stated that the phone number documented in the clinical note was incorrect and the Registered Nurse likely made a typographical error. Home Visit Patient #6- This 76- year- old patient, living in a skilled nursing facility with a terminal diagnosis of senile degeneration of the brain was admitted to the agency on 02/29/2024. Review of the Initial Comprehensive visit dated 02/29/2024 revealed that the Registered Nurse documented the patient was “;to wear compression sleeves to the arms with instructions to elevate limbs.” During an observational home visit on 03/19/2024 at 01:23 PM it was observed that the patient was not wearing compression sleeves. Review of the facilities Treatment Record for 03/19/2024 lacks documented evidence of an order for compression sleeves. Review of the Physicians Orders/ Plan of Care from 02/29/2024 to 05/28/2024 lacks documentation of an order for the compression sleeves. During interview on 03/27/2024 at 11:56 AM, the Case Manager stated the patient refuses the compression sleeves and there should be further documentation to clarify.”

“Based on review of clinical records and interviews with staff, for two (2) of twenty- seven (27) patients (Patient #s: 1, and 8) the hospice failed 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. Patient #8- This 93-year-old patient with a terminal diagnosis of multiple sclerosis was admitted to the hospice on 12/16/2023. Review of Physicians Orders/Plan of Care from 12/16/2023 to 03/14/2024 revealed the attending physician signed the Plan of Care on 01/10/24. Review of the clinical record dated 12/16/2023 to 03/26/2024 lacks a physician signature log for the attending physician that signed the Plan of Care. During an interview on 03/26/2024 at 10:38 AM, the Assistant Director of Hospice and Palliative Care stated the physician signature log dated 07/09/2019 does not include the attending physicians name change and has not been updated by the agency. The hospice failed to authenticate physician’s signatures and titles as evidenced by the following: Patient #1- This 71-year-old patient with the terminal diagnosis of acute kidney failure, unspecified was admitted to the hospice on 03/05/2024. Review of the Hospice Care Center- Admission Orders dated 3/11/2024 revealed the Physicians signature and title are present but the signature is illegible. Review of the Physicians Order Sheet: Drug and Intravenous Orders dated 03/11/2024 revealed the Medical Doctors signature and title are present but the signature is illegible. Review of the clinical record from 03/19/2024 to 03/28/2024 lacked documented evidence of a Physician Signature Log for a physician with this signature and title. During interview on 03/28/2024 at 08:55 AM, the Registered Nurse stated that the physicians signature on the admission and physicians order sheet belongs to one of the medical directors. During interview on 03/28/2024 at 10:10 AM, the Clinical Regulatory Compliance Specialist stated that the Physician Signature Log has been sent to that medical director, but it has not been completed and returned yet.”

“Based on a review of clinical records and staff interview for one (1) of three (3) live discharged patients (Patient #10), the hospice failed to ensure the attending physician was notified and provided a copy of the hospice discharge summary upon revoking the hospice benefit. Failure to notify and provide a discharge summary to the patients physician places patients at risk for poor coordination of patient services and unmet patient needs upon discharge from the hospice. The hospice failed to notify and provide the attending physician the patients discharge summary upon revocation as evidenced by the following: Patient #10 – This 58-year-old patient with a terminal diagnosis of end stage chronic obstructive pulmonary disease was admitted to the hospice on 10/04/2023. Review of the Hospice Revocation and Clinical Note dated 10/17/2023 revealed the patient was revoking the hospice benefit to pursue hospitalization. Review of the Agency Discharge Summary dated 10/17/2023 lacks documented evidence the attending physician was notified and provided a copy of the discharge summary from the hospice. Review of the clinical record lacks documentation the attending physician was notified of the patients revocation from hospice and provided a copy of the discharge summary. During interview on 03/26/2024 at 12:56 PM, the Registered Nurse stated she completed the revocation with the patient and was instructed the Supervisor would notify the physician, but there is no documentation this occurred. During interview on 03/26/2024 at 12:58 PM, the Clinical Regulatory Compliance Specialist stated the Agency Discharge Summary is a compiled document from multiple reports and not completed by one individual. She acknowledged there is no documentation the discharge summary was sent to the attending physician.”

“Based on clinical record review and staff interview the hospice failed to ensure a comprehensive discharge summary was prepared that contained all required components for one (1) of three (3) live discharged patients (Patient #10). 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 #10 – This 58-year-old patient with a terminal diagnosis of end stage chronic obstructive pulmonary disease was admitted to the hospice on 10/04/2023. Review of the Agency Discharge Summary dated 10/17/2023 due to the patient revoking hospice services lacks the following required components: - A summary of the patients stay including treatments, symptoms and pain management; and - The patients latest physician orders. During interview on 03/26/2024 at 12:58 PM, the Clinical Regulatory Compliance Specialist stated the Agency Discharge Summary is a compiled document from multiple reports and not completed by one individual. She acknowledged the discharge summary does not contain all the required components.”

“Based on review of hospice policies and procedures, patient record reviews, surveyor observations and staff interview for one (1) of one (1) patients (Patient #1) in the hospice in-patient facility receiving intravenous push medications, the hospice failed to ensure the Registered Nurse administered intravenous medications in accordance with hospice policies and procedures. Failure to follow agency policy and procedure has the potential to place both staff and patients at risk of negatives outcomes and potential harm. The hospice failed to ensure the Registered Nurse administered intravenous medication in accordance with hospice policies as evidenced by the following: Home Visit Patient #1- This 71-year-old patient with the terminal diagnosis of acute kidney failure, unspecified was admitted to the hospice on 03/05/2024. At the time of the survey, the patient was receiving hospice care in the hospice in-patient facility. Review of the agencys policy entitled “;Intravenous Push Medication Administration” dated 08/2023 revealed: “;3. Refer to intravenous push reference list for the Registered Nurse approved dose limits and administration guidelines for each medication. Dose limits and administration guidelines must be followed for safe administration.” Review of the undated policy entitled “Intravenous Push Medication Reference- All Areas” revealed “Medication: Hydromorphone (Dilaudid), Approved Registered Nurse Dose: Rate: 2 milligrams over two (2) minutes...Medication: Lorazepam (Ativan), Approved Registered Nurse Dose: Rate: Not to exceed 2 milligrams per minute.” Review of agency policy entitled “;Infusion: Vascular Devices/ Infusion Related Procedures dated 02/2024 revealed, “Venous Access Device Care Guidelines, Policy #5008, Table A, Adult...Type of Access: Tunneled and Non-Tunneled Central Catheters, Flushes: 10 milliliters Sterile Normal Saline, before/ after therapy or daily when not being used to each lumen, Heparin 10 units/ milliliter) 5 milliliters as last flush to each lumen.” Review of the Physicians Order Sheet dated 03/13/2024 revealed the following ordered medications: - Hydromorphone 2 milligrams, intravenously, every four (4) hours around the clock and every one (1) hour as needed for pain/ dyspnea, maximum daily dose: 60 milligrams. - Lorazepam 1 milligram, intravenously, every four (4) hours around the clock and every one (1) hour as needed for anxiety, restlessness, insomnia or seizures, maximum daily dose: 30 milligrams. During Inpatient Unit Facility Survey on 03/19/2024 at 12:05 PM, the surveyor observed the Registered Nurse administer the patients scheduled intravenous medications. In the medication room the surveyor observed the Registered Nurse do the following: Draw up Lorazepam from a multi-use vial medication into 1 milliliter syringe then with the same syringe, drew up the Dilaudid from a single use vial. The Registered Nurse the took a 10 milliliter syringe filled with normal saline, squirted 5 milliliters of saline into the med room sink, then drew back on the syringe to create an air bubble. The Registered Nurse then took the syringe filled with the mixed medications and inserted the needle into the port of the saline filled syringe and emptied the medication into the saline filled syringe. In the patients room, the Registered Nurse cleaned the patients central line port with alcohol, flushed the line with 5 cc of normal saline, cleaned the port again with alcohol, then administered the diluted medication mixture. Removed the syringe, cleaned the port again, then flushed the port with 5cc normal saline. The flushes, and medication administration were all completed within one minute. Review of the patient record from 03/11/2024 (date of Inpatient Unit admission) to 03/19/2024 lacked documented evidence of an order to combine and administer Hydromorphone and Lorazepam together. During interview on 03/26/2024 at 09:32 AM, the observations and findings were discussed with the Registered Nurse. The Registered Nurse stated that she referenced the hospices online resource (Lexicomp) regarding whether Dilaudid and Lorazepam could be mixed, and the resource states that the medications are compatible. At 09:48 AM, the Registered Nurse stated that the hospice policy states the maximum administration rate is 2 milligrams per minute for Lorazepam and the Registered Nurse stated, “;I know the medications were not given over two (2) to five (5) minutes.””

“Based on clinical record review, agency policy and procedure and staff interview for three (3) of eleven (11) patients (Patient #’s: 4, 12 and 21), the hospice failed to ensure supervision of the Baccalaureate Social Worker (BSW). Failure to ensure the Baccalaureate Social Worker is adequately supervised has the potential of providing inadequate care. The hospice failed to ensure the bachelors degree Social Worker was adequately supervised as evidenced by the following: Review of the agency policy and procedure entitled “;Hospice Scope of Services” updated 11/2023 revealed V. “All unlicensed social work staff will have their initial assessments and orders co-signed by a licensed Social Worker.” Employee F – This bachelors degree Social Worker was hired by the hospice on 10/01/2019. Patient #12 – This 75-year-old patient with the terminal diagnosis of malignant melanoma of right lower limb including hip was admitted to the hospice on 01/22/2023. Review of the Social Work Bereavement Initial Visit Note dated 02/14/2023 revealed Employee F performed the visit. The visit notes lacks documentation of being reviewed and signed by a Master Social Worker. During interview on 03/26/2024 at 09:59 AM, the Manager of Family Life Services stated he communicated with the social worker but did not know the identified visit had to be cosigned by the Master Social Worker. Employee TT – This bachelors degree Social Worker was hired by the hospice on 09/25/2023. Patient #21 – This 67-year-old patient with the terminal diagnosis of secondary malignant neoplasm of breast was admitted to the hospice on 03/04/2024. Review of the Social Work Initial Visit Note dated 03/04/2024 revealed Employee TT performed the visit. The visit notes lacks documentation of being reviewed and cosigned by a Master Social Worker. During interview on 03/27/2024 at 01:12 PM, the Clinical Regulatory Compliance Specialist stated the visit was not cosigned by the Master Social Worker but should be. The hospice failed to ensure the Baccalaureate Social Worker was adequately supervised as evidenced by the following: Review of the agency policy and procedure entitled “;Hospice Scope of Services” revised 11/2023 revealed “;V. All unlicensed social work staff will have their Initial Assessments and orders co-signed by a licensed Social Worker.” Patient #4 – This 90-year-old patient, residing in an assisted living facility, with a terminal diagnosis of senile degeneration of the brain was admitted to the hospice on 03/04/2024. Review of the clinical record revealed a Social Work Initial Visit occurred on 03/07/2024 and was conducted by Employee TT, a Baccalaureate Social Worker. Review of the Supplemental Order dated 03/07/2024 revealed the following orders written by Employee TT: - Medical Social Services (MSS) one (1) to four (4) times monthly for three (3) months with four (4) as needed visits for status changes. Medical Social Services to assess areas of coping issues, grief therapy to facility coping, educate and support related to the grief process, provide end of life education/ support to patient/ family, psycho- social assessment and Masters in Social Work (MSW) skilled assessment. The Supplemental Order lacks documentation of being co-signed by a licensed Social Worker. During interview on 03/27/2024 at 02:52 PM, the Clinical Regulatory Compliance Specialist stated she would look for additional documentation for the order. No further documentation was provided.”

“Based on review of agency policy and procedure, the hospice’s training curriculum, personnel records and interviews with agency staff, the hospice failed to ensure the hospice developed a comprehensive restraint and seclusion policy and ensured that all patient care staff working in the hospice inpatient unit receive training on the safe use of restraints and seclusion. Failure to properly train staff on the use of restraints and seclusion has the potential to put hospice patients health and welfare at risk. Review of the agency policy and procedure entitled “;Hospice Care Center Use of Restraints Policy” dated 08/2023 revealed the policy does not include the following information to ensure the policy is written in accordance with State law: -Restraints or seclusion are used only after less restrictive interventions have been determined to be ineffective to protect the patient, staff, or others from harm. -The type of technique of restraint or seclusion used is the least restrictive intervention. -The use of a restraint is in accordance with a written modification of the patients plan of care and implementation is in accordance with safe and appropriate techniques. -Orders for the use of restraints or seclusion are never written as a standing order or on an as needed basis. -The medical director/physician designee is consulted as soon as possible if the attending physician did not order the restraint or seclusion. -Each order for restraint or seclusion may only be renewed in accordance with age and restraint/seclusion limitations for up to a total of 24 hours (for adults 18 years or older, the limit is 4 hours). After 24 hours, before a new order is written, a physician authorized to order restraints or seclusion must see and assess the patient. -The restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. -The condition of the restrained or secluded patient must be monitored by an appropriately trained physician or staff at an interval determined by hospice policy. -The patients right to safe implementation of restraints or seclusion by staff who have been appropriately trained and have demonstrated competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a restrained or secluded patient. -Training intervals to include training and demonstration of competency as part of orientation, and subsequently on a periodic basis. -Training content and requirement for physicians and appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population to include: -Techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of a restraint or seclusion. -The use of nonphysical intervention skills. -Choosing the least restrictive intervention based on individualized assessment of the patients medical, or behavioral status or condition. -The safe application and use of all types of restraints or seclusion used in the hospice, including training on how to recognize and respond to signs of physical and psychological distress (for example, positional asphyxia). -Clinical identification of specific behavioral changes that indicate restraint or seclusion is no longer necessary. -Monitoring the physical and psychological well- being of the patient who is restrained or secluded, including but not limited to, respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified by the hospice policy associated with the one (1) hour face to face evaluation. -The use of first aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic recertification. -Trainer Requirements to ensure that staff who conduct the training are qualified as evidenced by education, training, and experience in techniques used to address patients behaviors. -Training documentation. The hospice must document in the staff personnel records that the training and demonstration of competency were successfully completed.” -The requirement that the patient must be seen face-to -face within 1 hour after initiation of the intervention by an appropriately physician or Registered Nurse to evaluate the patients condition, reaction/response to the intervention, need to continue or terminate the intervention. -Documentation requirements regarding the one-hour face to face medical and behavioral evaluation, description of the patients behavior and intervention used, alternative or less restrictive interventions attempted, and the patients condition tat warranted the use of a restraint or seclusion, the patients response to the intervention used, and the rationale for continued use of the intervention. During interview on 03/27/2024 at 10:23 AM, the Clinical Regulatory Compliance Specialist stated that the agency restraint policy is used for both the orientation and annual restraint training curriculum. Additionally, at 10:34 AM, the Clinical Regulatory Compliance Specialist stated that the policy/ training curriculum is missing the required regulatory language and competencies. The Clinical Regulatory Compliance Specialist stated that currently demonstration is not part of the orientation or annual in-service training but if a restraint was needed, that an immediate staff refresher training would be completed before application. B. Employee JJJ- This Masters Social Worker was hired by the hospice on 09/18/2023. This employee provides services to patients in the hospices In-patient Unit. Review of Employee JJJs personnel record from 09/18/2024 to 03/21/2024 lacks documented evidence that the employee received orientation training on the use of restraints and seclusion since hire. During interview on 03/27/2024 at 10:26 AM, the Clinical Regulatory Compliance Specialist stated that there is no documented evidence of restraint or seclusion training for Employee JJJ since hire.”