Vnsny Hospice and Palliative Care

“Based on clinical record reviews and staff interview, the hospice failed to ensure that Hospice Aides provide services in accordance with the Paraprofessional Plan of Care. This was evident for one (1) of three (3) clinical records reviewed (Patient #1). Failure to ensure all Hospice Aides provide services in accordance with the Paraprofessional Plan of Care, has the potential for negative patient outcomes. The Findings Are: 1. Patient #1 has Start of Care date of 10/20/2025 with the following diagnoses “Heart Failure, Chronic Obstructive Pulmonary Disease, Unspecified Asthma with (Acute) Exacerbation” documented on the Hospice Certification and Plan of Care for Certification Periods 10/20/2025 to 01/17/2026. The Paraprofessional Plan of Care for 10/20/2025 to 01/17/2026 documents the following tasks: “Bath: Sponge, Dressing, Incontinent care, Laundry, Clean” The Duty Sheet dated 11/4-11/7 documents the following tasks: “B/P (Blood Pressure), Respiration, Pulse, Walking: Assist, Assist with Feeding.” There is no documented evidence of the Hospice Aides providing services in accordance with the Paraprofessional Plan of Care. On 12/18/2025 at 12:30 PM, the Hospice Quality Manager was interviewed and did not provide an explanation for the findings.”

“Based on clinical record reviews and staff interview, the hospice failed to ensure that Hospice Aides report all concerns about the patient or family. This was evident for one (1) of three (3) clinical records reviewed. (Patient #1). Failure to ensure that all concerns are reported, has the potential for negative patient outcomes. The Findings Are: 1. Patient #1 has Start of Care date 10/20/2025 with the following diagnoses “Heart Failure, Chronic Obstructive Pulmonary Disease, Unspecified Asthma with (Acute) Exacerbation” documented on the Hospice Certification and Plan of Care for Certification Periods 10/20/2025 to 01/17/2026. The Paraprofessional Plan of Care for 10/20/2025 to 01/17/2026 documents following tasks: “Bath: Sponge.” The investigation summary dated 12/17/25, at 10:05 AM documents: “(Employee #1) statement: Upon arrival at 9:00 AM, the patient was seated in a chair. The daughter instructed the aide to give the patient a shower. The aide asked the patient immediately, but he refused. When asked again as he exited the bathroom, the patient said yes in two hours. The aide informed the daughter of the refusal, and she acknowledged that the patient dislikes showers and had not showered for at least two weeks. She requested the aide to try again later.” The clinical record lacks documented evidence of Employee #1 notifying the agency that patient’s family requesting completion of the task that is not a part of the Paraprofessional Plan of Care. On 12/18/2025 at 12:30 PM, the Hospice Quality Manager was interviewed and did not provide an explanation for the findings.”

“Based on clinical record reviews and interviews, the hospice failed to ensure all individualized Plan of Care(s) are followed. This was evident for one (1) of three (3) clinical records reviewed (Patient #1).Failure to ensure that an individualized Plan of Care is followed, has the potential for negative patient outcomes.The finding is:1. Patient #1 has a Start of Care date of 10/15/2025 with the following diagnoses “Malignant Neoplasm of Pancreas with Hepatic Metastases” documented on the Hospice Certification and Plan of Care for the Certification Period 10/15/2025 to 01/12/2026.The Hospice Physician Order dated 10/18/2025 documents: HHA (Home Health Aide) Service “21 HRS/WEEK (Twenty-one hours a week). Service Changes: Calendar Frequency: HHA (Home Health Aide) Effective 10/19/2025 6WK1, 7WK11, 2WK1 (Six times a week for one week, seven times a week for eleven weeks, twice a week for one week)”.The Hospice Physician Order dated 10/22/2025 documents: HHA (Home Health Aide) Service 12 HRS 8 PM to 8 AM (Twelve hours from eight o’clock in the evening to eight o’clock in the morning) 10/22, 10/23, 10/24.The Duty Sheet by Visit Date documents aide services being provided on: 10/22/2025. The clinical record lacks documented evidence of aide providing services for the week of: 10/19/2025 to 10/25/2025 – missed three visits. There is no documented evidence of the patient receiving aide services as ordered in the plan of care.On 11/06/2025 at 03:40 PM, the Administrators and Quality improvement Manager were interviewed and did not provide an explanation for the findings.”

“Based on clinical record reviews and staff interviews, the hospice failed to ensure comprehensive assessments identifies all the patient’s needs. This was evident for two (2) of thirty (30) clinical records reviewed. (Patients #11, and #25). Failure to ensure that a comprehensive assessment identifies all the patient ‘s needs has the potential for negative patient outcomes. The Findings Are: 1. Patient #11 has a Start of Care date of 09/09/2024 with the following diagnoses “Malignant Neoplasm of Ovary, Anxiety Disorder” documented on the Hospice Certification and Plan of Care for the Certification Period 09/09/2024 to 12/07/2024. The Visit Note Report dated 09/09/2024, 09/10/2024, 09/12/2024, 09/16/2024, 09/17/2024, 09/18/2024, and 09/23/2024 documents: “;Does the patient have infusion access: NO.” The Visit Note Report dated 09/23/2024 documents: Does the patient have infusion access: YES; Type of infusion access: Port, implanted, vascular access port; Indicate when port was last accessed: accessed prior to visit; Indicate date when port was last accessed: 3 weeks ago. The Initial assessment and comprehensive assessments before 09/23/2024 lacks documented evidence of the chest port. On 10/18/2024 at 03:00 PM, the Administrators/Directors of Clinical Services/ Directors of Patient Services (Senior Vice President Hospice and Palliative Care, Vice President Clinical Operations) and staff were interviewed and did not provide an explanation for the findings. 2. Patient #25 has a Start of Care date of 01/09/2024 and a discharge date of 01/30/2024 with the following diagnoses “Heart Failure, Vascular Dementia” documented in the Hospice Certification and Plan of Care for the Certification Period 01/09/2024 to 04/07/2024. The Hospice Certification and Plan of Care for the Certification Period 01/09/2024 to 04/07/2024 documents: “;Hospice nurse to perform the following wound care to pu (pressure ulcer) to Sacrum.” The Visit Note Report (Hospice Admission assessment) dated 01/09/2024 documents: Mid Sacral pressure ulcer Injury; Unable to measure; No granulation tissue present; Epithelialization: <25% wound covered; Necrotic Tissue Amount: None visible.” The Hospice Physician Order dated 01/12/2024 documents: “;Hospice Nurse to perform the following wound care to pu (pressure ulcer) to Sacrum utilizing clean technique – Cleanse with soap and water pat dry, apply Barrier Cream to surrounding skin, leave open to air, apply MediHoney to Stage III open area and cover with Foam bordered gauze pad. The Initial / comprehensive assessments lack documented evidence of a wound assessment that includes staging, measurement, and description as documented in the Hospice Physician Order. On 10/18/2024 at 03:00 PM, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings.”

“Based on clinical record reviews and staff interviews, the hospice failed to ensure that all comprehensive assessments are updated. This was evident for four (4) of thirty (30) clinical care records reviewed (Patient #1, #9, #10, and #12). Failure to ensure that all comprehensive assessment are updated, has the potential for negative patient outcomes. The Findings Are: *. Patient #9 has a Start of Care date of 08/01/2023 with the following diagnosis “Senile Degeneration of Brain” documented in the Hospice Certification of Terminal Illness for the Certification Period 07/26/2024 to 09/23/2024 and 09/24/2024 to 11/22/2024. The clinical record documents registered nurse visit on 09/05/2024, 09/26/2024 (21 days), and 10/18/2024 (22 days). The clinical record lacks documented evidence of an update of the comprehensive assessment that includes patients progress toward desired outcomes and response to care no less frequently than every 15 days. On 10/17/2024 at 02:35pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. *. Patient #10 has a Start of Care date of 09/03/2024 with the following diagnoses “Alzheimers Disease, Dementia” documented in the Hospice Certification of Terminal Illness for the Certification Period 09/03/2024 to 12/01/2024. The Plan of Care Update dated 09/17/2024 documents: Hospice nurse to perform wound care one time a week to Unstageable wound in Left Heel area. Utilizing clean technique – cleanse with Normal Saline, apply Iodine and pad with gauze cover with a Silicone Foam or Composite Dsg BIW & PRN (dressing twice a week and as needed). The Visit Note Report documents Left Heel, Unstageable DTI (deep tissue injury):09/17/2024 Epithelialization: <25%; slough: 76-100%; Eschar: 76-100%.10/08/2024 Epithelialization: 75-<100%; Necrotic amount: None. The clinical record lacks documented evidence of the update of wound by staging wound, necrosis resolved, only epithelialization.There is no documented evidence of an updated comprehensive assessment. On 10/17/2024 at 02:35pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. *. Patient #12 has a Start of Care date of 04/05/2024 with the following diagnosis “Senile Degeneration of Brain” documented in the Hospice Certification of Terminal Illness for the Certification Period 07/04/2024 to 10/01/2024. The Hospice Recertification Plan of Care Update for the Certification Period 07/04/2024 to 10/01/2024 documents: “;Hospice nurse to perform the following wound care to (pressure ulcer to Sacrum). Utilizing clean technique – Cleanse Stage 3 pressure ulcer with NS (normal saline), pat dry apply MediHoney to wound bed, and Zinc Oxide to periwound cover with Opti Foam and change q (every) shift and PRN (as needed).” The Visit Note Report (Recertification Assessment) dated 06/14/2024 documents: “;Does the patient have active wounds? NO; No additional integumentary assessment findings.” The Visit Note Report dated 07/09/2024, 07/15/2024, 07/23/2024 documents: “;Does the patient have active wounds? NO; Additional Integumentary Observation Findings: No problems identified.” The comprehensive assessment lacks documented evidence of the update of wound – no wound. The Visit Note Report documents: 08/01/2024 Mid Posterior Sacral pressure ulcer stage III. Reactivate wound – recurrence (no measurement or description of wound).08/09/2024 (no measurement or description of wound).08/16/2024 Mid Posterior Sacral pressure ulcer stage III; Epithelialization: 75-<100%; Necrotic Tissue Amount: None.08/21/2024 (no measurement or description of wound).08/27/2024 Mid Posterior Sacral pressure ulcer stage III; Epithelialization: 75-<100%; Necrotic Tissue Amount: None.09/10/2024 Mid Posterior Sacral pressure ulcer stage III; Granulation Tissue: 75-100%; Epithelialization: 100%; Necrotic Tissue Amount: None.09/18/2024 and 09/28/2024 (no measurement or description of wound). The comprehensive assessments lack documented evidence of the wound assessment and response to care every 15 days.There is no documented evidence of an updated comprehensive assessment. On 10/18/2024 at 03:00pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. 1. Patient #1 has a Start of Care date of 07/14/2024 with diagnosis of Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung documented in the “Hospice Certification and Plan of Care” for Certification Period 07/14/2024 to 10/11/2024. The “Hospice Certification and Plan of Care” for Certification Period 07/14/2024 to 10/11/2024 documents: “;Hospice RN (Registered Nurse) to evaluate patient and develop a nursing plan of care in collaboration and in agreement with the patient/representative.” The Skilled Nurse/Registered Nurse “;Visit Note Report” dated 08/02/2024 documents: “;Patient has a rash between buttocks that appears to be vulnerable to pressure from sitting on wheelchair all day. Skin carefully monitored by RN (Registered Nurse) over next few weeks.” The Registered Nurse Recertification Assessment “;Visit Note Report” dated 09/20/2024 documents: “;Patient is spending much more time in bed or sitting in his chair and has developed what appears to be a stage two pressure ulcer over coccyx. At time of charting nurse awaiting word from wound care (consult) as to how to address the wound. For the time being patient is using silicone bordered phone (foam) patches to pad area affected and offloading whenever possible.” The Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report for meeting Date 09/24/2024 lacks documented evidence of the patient developing a stage two pressure ulcer over the coccyx. The “;Initial and Comprehensive Assessment” Policy (Revised April 2024) documents: the comprehensive assessment includes assessment of “;skin integrity (including a full assessment of wounds).” The “;Wound Assessment and Escalation” Policy (Revised April 2023) documents: A comprehensive wound assessment includes a clinical evaluation of the wound bed, periwound, and each risk factor;” timeframe for wound assessment is “;at the time of the onset of a new wound;” “;the size of the wound is measured once weekly as tolerated.” The Registered Nurse Recertification Assessment “;Visit Note Report” dated 09/20/2024 and the subsequent weekly Skilled Nurse/Registered Nurse Visit Note Report(s) dated 09/27/2024 and 10/04/2024 lacks documented evidence of a comprehensive wound assessment, including measurement, in accordance with the agencys policies. The clinical record lacks documented evidence of the hospice nurse updating the comprehensive assessment to reflect changes in the patient’s skin integrity, including at onset of a new wound and an ongoing wound comprehensive assessment. On 10/17/2024 at 2:35pm, the Administrator, the Vice President of Quality, the Directors of Clinical Services/Directors of Patient Services, and staff were interviewed and did not provide an explanation for the survey findings.”

“Based on clinical record reviews and interviews, the hospice failed to ensure all individualized Plan of Care(s) are followed. This was evident for two (2) of thirty (30) clinical records reviewed. (Patients #3, and #11). Failure to ensure that an individualized Plan of Care is followed, has the potential for negative patient outcomes. The Findings Are: *. Patient #11 has a Start of Care date of 09/09/2024 with the following diagnoses “Malignant Neoplasm of Ovary, Anxiety Disorder” documented in the Hospice Certification and Plan of Care for the Certification Period 09/09/2024 to 12/07/2024. The Hospice Physician Order dated 09/09/2024 documents: hha (home health aide) “3WK1, 5WK12 (three times a week for one week, five times a week for twelve weeks)”. The Duty Sheet by Visit Date documents aide services being provided on: 09/11/2024, 09/13/2024, 09/16/2024, 09/18/2024, and 09/20/2024. The clinical record lacks documented evidence of aide providing services for the week of: 09/09/2024 to 09/14/2024 – missed one visits, 9/15/2024 to 09/21/2024 – missed two visits. There is no documented evidence of the patient receiving aide services as ordered in the plan of care. On 10/18/2024 at 03:00pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. 1. Patient #3 has a Start of Care date of 09/01/2024 with diagnoses of Malignant Neoplasm of Colon Unspecified, Secondary Malignant Neoplasm of Retroperitoneum and Peritoneum, Constipation Unspecified, Chronic Embolism and Thrombosis of Unspecified Deep Veins of Unspecified Lower Extremity documented in the “Hospice Certification and Plan of Care” for Certification Period 09/01/2024 to 11/29/2024. The Plan of Care Update dated 09/03/2024 documents: “;Home Health Aide for assistance with personal care, hygiene and activities of daily living; (home health aide) frequency 5Days x 2 Hours (five days a week times two hours a day).” The vendor Coordination Note – Home Health Aide Request dated 09/03/2024 documents the following request: “;(Home Health Aide) Order schedule “;5 Days x 2 Hours (Mon-Fri) 3PM-5PM;” and “;Start Date requested: 9/4/2024.” The “;Duty Sheet By Visit Date” dated 09/01/2024 to 09/30/2024 documents aide services started on 09/13/2024, not on 09/04/2024 as requested. The clinical record lacks documented evidence of communication with the patient/family regarding the delay providing home health aide services. The “;Duty Sheet By Visit Date” dated 09/01/2024 to 09/30/2024 and 10/01/2024 to 10/16/2024 lacks documented evidence of home health aide services being provide on 09/23/2024 (Monday), 10/07/2024 (Monday), and 10/08/2024 (Tuesday). The Coordination Note dated 09/24/2024 documents: “;(patient family member) is not happy that no one showed up yesterday (09/23/2023). They (Family/patient) leave the door open for the evening aide. (Family member) does not want to continue leaving the door open if no one will show up. (The caller) also stated the aide needs to change the patient before leaving. (Family) has a camera & no one has changed the pt(patient) before leaving.” There is no documented evidence of the collaboration and notification of the missed visits to the Physician and patient/family. There is no documented evidence of home health aide services being furnished in accordance with the hospice plan of care and the patients needs. On 10/17/2024 at 2:35pm, the Administrator, the Vice President of Quality, the Directors of Clinical Services/Directors of Patient Services, and staff were interviewed and did not provide an explanation for the survey findings.”

“Based on clinical record reviews and interviews, the hospice failed to ensure that each patient and the primary care giver(s) receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care. This was evident for one (1) of thirty (30) clinical records reviewed. (Patients #1). Failure to ensure that each patient and the primary care giver(s) receive education, has the potential for negative patient outcomes. The Findings Are: 1. Patient #1 has a Start of Care date of 07/14/2024 with diagnosis of Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung documented in the “Hospice Certification and Plan of Care” for Certification Period 07/14/2024 to 10/11/2024. The Skilled Nurse/Registered Nurse “;Visit Note Report” dated 08/02/2024 documents: “;Patient has a rash between buttocks that appears to be vulnerable to pressure from sitting on wheelchair all day. Skin carefully monitored by RN (Registered Nurse) over next few weeks.” The RN (Registered Nurse) Recertification Assessment “;Visit Note Report” dated 09/20/2024 documents: “;Patient is spending much more time in bed or sitting in his chair and has developed what appears to be a stage two pressure ulcer over coccyx.” The clinical record lacks documented evidence of the skilled nurse educating the patient/primary care giver(s) on how to prevent the patient from developing a pressure ulcer. On 10/17/2024 at 2:35 PM the Administrators/Directors of Clinical Services/ Directors of Patient Services (Senior Vice President Hospice and Palliative Care, Vice President Clinical Operations) and staff were interviewed and did not provide an explanation for the survey finding.”

“Based on clinical record reviews and staff interviews, the hospice failed to ensure individualized Plan of Care is developed for each patient. This was evident for one (1) of thirty (30) clinical records reviewed. (Patients #12). Failure to ensure that individualized Plan of Care is developed for each patient, has the potential for negative patient outcomes. The Findings Are: 1. Patient #12 has a Start of Care date of 04/05/2024 with the following diagnosis “Senile Degeneration of Brain” documented in the Hospice Certification of Terminal Illness for the Certification Period 07/04/2024 to 10/01/2024. The Hospice Recertification Plan of Care Update for the Certification Period 07/04/2024 to 10/01/2024 documents: “;Hospice nurse to perform the following wound care to (pressure ulcer) to Sacrum. Utilizing clean technique – Cleanse Stage 3 pressure ulcer with NS (normal saline), pat dry apply MediHoney to wound bed, and Zinc Oxide to periwound cover with Opti Foam and change q (every) shift and PRN (as needed).” The Visit Note Report (Recertification Assessment) dated 06/14/2024 documents: “;Does the patient have active wounds? NO; No additional integumentary assessment findings.” The Visit Note Report dated 07/09/2024, 07/15/2024, 07/23/2024 documents: “;Does the patient have active wounds? NO; Additional Integumentary Observation Findings: No problems identified.” The Plan of Care lacks documented evidence of the updated status of - no wound. On 10/18/2024 at 03:00 PM, the Administrators/Directors of Clinical Services/ Directors of Patient Services (Senior Vice President Hospice and Palliative Care, Vice President Clinical Operations) and staff were interviewed and did not provide an explanation for the findings.”

“Based on clinical record reviews and staff interviews, the hospice failed to ensure the individualized Plan of Care includes all medication and treatments as ordered by the Physician . This was evident for two (2) of thirty (30) clinical records reviewed. (Patients #1, and #19). Failure to ensure the individualized Plan of Care includes all medication and treatments as ordered by the physician for each patient has the potential for negative patient outcomes. The Findings Are: 1. Patient #19 (Home Visit) has a Start of Care date of 9/16/2024 with diagnoses of Malignant Neoplasm of Biliary Tract, Unspecified documented on the Hospice Certification and Plan of Care with a Certification Period from 9/16/2024 to 12/14/2024. On 10/15/2024 a Home Visit was conducted, and the oxygen safety sign was observed on the Patient #19s bedroom door and the oxygen concentrator were present in the Patient #19s bathroom. The LPN (Licensed Practical Nurse) was interviewed and stated Patient #19 can use the oxygen whenever he needs it. There is no documented evidence of Physicians Order for the use of oxygen. On 10/17/2024 at 02:35pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. 1. Patient #1 has a Start of Care date of 07/14/2024 with diagnosis of Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung documented in the “Hospice Certification and Plan of Care” for Certification Period 07/14/2024 to 10/11/2024. The Skilled Nurse/Registered Nurse “;Visit Note Report” dated 08/02/2024 documents: “;Patient has a rash between buttocks that appears to be vulnerable to pressure from sitting on wheelchair all day. Skin carefully monitored by RN (Registered Nurse) over next few weeks.” The Registered Nurse Recertification Assessment “;Visit Note Report” dated 09/20/2024 documents: “;Patient is spending much more time in bed or sitting in his chair and has developed what appears to be a stage two pressure ulcer over coccyx. At time of charting nurse awaiting word from wound care (consult) as to how to address the wound. For the time being patient is using silicone bordered phone (foam) patches to pad area affected and offloading whenever possible.” The NP (Nurse Practitioner) Wound Care Consult Coordination Note dated 09/23/2024 documents: “;Consult Request Date: 9-20-24 Time: 2:04PM;” “;Recommendations/Verbal Order Given: Date 9-20-24 Time: 2:37PM;” “;Received picture of sacral area with what appears to be a Stage 3 PI (Pressure Injury) from (Registered Nurse/Skilled Nurse);” “;Recommendations: Wound cleansee, a dab of honey wound gel to the wound, skin prep to protect periwd (periwound), pad with gauze, cover with a silicone foam or composite dsg (dressing) BIW (twice a week) & PRN (as needed), offload;” “;reinforce pressure injury prevention measures as appropriate.” The NP (Nurse Practitioner) Coordination Note documents that a verbal order for wound care was given on 09/20/2024. The NP (Nurse Practitioner) Wound Care Consult Coordination Note dated 09/26/2024 documents: “;Consult Request Date: 9-25-24 Time: 3:55PM;” “;Recommendations/Verbal Order Given: Date 9-25-24 Time: 3:57PM;” “;Received additional picture of Sacral Stage 3 PI (Pressure Injury) form (Registered Nurse/Skilled Nurse);” “;Recommendations: Continue honey wound gel, periwound protection BIW (twice a week) & PRN (as needed), ongoing offloading.” The subsequent weekly Skilled Nurse/Registered Nurse Visit Note Report(s) dated 09/27/2024 and 10/04/2024 lacks documented evidence of the Skilled nurse performing wound care. The clinical record lacks documented evidence of wound care being performed twice a week. The Hospice Physician Order dated 10/10/2024 documents the Skilled Nurse/Registered Nurse entered the recommendations/verbal order for wound care twenty (20) days after the order was given. The Hospice Physician Order dated 10/10/2024 documents the following wound care order: “;Using Clean technique, cleanse wound with normal saline or wound cleanser, apply a dab of medical honey, apply a piece of gauze to wound, apply barrier film to periwound and cover with silicone foam dressing. Perform wound care biweekly (twice a week) or PRN (as needed). VNS nurses will perform wound care during weekly visit.” There is no documented evidence of the Skilled Nurse immediately documenting the verbal orders for wound care to ensure plan of care is revised and the patients wound care needs are addressed in a timely manner. On 10/17/2024 at 2:35pm, the Administrator, the Vice President of Quality, the Directors of Clinical Services/Directors of Patient Services, and staff were interviewed and did not provide an explanation for the survey findings.”

“Based on clinical record reviews and staff interviews, the hospice failed to ensure the Plan of Care includes medical supplies and appliances necessary to meet the needs of the patient. This was evident for one (1) of thirty (30) clinical records reviewed. (Patients #7). Failure to ensure that Plan of Care includes medical supplies and appliances necessary to meet the patient needs, has the potential for negative patient outcomes. The Findings Are: 1. Patient #7 has a Start of Care date of 08/22/2024 with the following diagnosis “Diffuse Large B-Cell Lymphoma” documented in the Hospice Certification and Plan of Care for the Certification Period 08/22/2024 to 11/19/2024. The Hospice Certification and Plan of Care for the Certification Period 08/22/2024 to 11/19/2024 documents: DME (durable medical equipment): wheelchair. The Visit Note Report dated 08/22/2024 documents: Existing equipment / supplies owned by patient: cane, walker, shower stool. The Plan of Care lacks documented evidence of the cane, walker and the shower stool. On 10/17/2024 at 02:35 PM the Administrators/Directors of Clinical Services/ Directors of Patient Services (Senior Vice President Hospice and Palliative Care, Vice President Clinical Operations) and staff were interviewed and did not provide an explanation for the findings.”

“Based on clinical record reviews and staff interviews, the hospice failed to ensure the Interdisciplinary Group reviewed and revised the individualized Plan of Care as the patient’s care needs change, but no less frequently than every fifteen (15) days. This was evident for eight (8) of thirty (30) clinical records reviewed. (Patients #1, #3, #6, #9, #10, #12, #16, and #20). Failure to ensure that the Interdisciplinary Group develop, review, and revise the POC, has the potential for negative patient outcomes. The Findings Are: *. Patient #9 has a Start of Care date of 08/01/2023 with the following diagnosis “Senile Degeneration of Brain” documented in the Hospice Certification of Terminal Illness for the Certification Period 07/26/2024 to 09/23/2024 and 09/24/2024 to 11/22/2024. The Client Episode Coordination Notes Report dated 07/28/2024 documents: “;Patient who is constipated for 8 days” “;Patient is not in pain related to BM (bowel movement) but is having pain to hip” “;she is very concerned about the new onset of pain to hip”. The Hospice Physician Order dated 07/28/2024 documents: “;Add Bisacodyl daily for constipation as needed; Add Lactulose 30 ml (milliliter) daily.” New order Morphine Concentrate 10mg every 2 hours/PRN (as needed) and discontinue Morphine 5 mg every 2 hours//PRN (as needed). The Hospice IDG (Interdisciplinary group) Comprehensive Assessment and Plan of Care Update Report dated 08/07/2024 documents: Summary of updates/issues/status/decline over the prior two weeks: blank. The Interdisciplinary group meeting on 07/24/2024 and 08/07/2024 lacks documented evidence of the review of the outcome of increasing pain medication and started on constipation medication. On 10/17/2024 at 02:35pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. *. Patient #10 has a Start of Care date of 09/03/2024 with the following diagnoses “Alzheimers Disease, Dementia” documented in the Hospice Certification of Terminal Illness for the Certification Period 09/03/2024 to 12/01/2024. The Client Episode Coordination Notes Report documents:09/23/2024 “;Pt (patient) is now interested in volunteer services” “;Pts (patients) daughter is also interested in receiving a Hoyer Lift since it has become increasingly difficult to transfer pt (patient).”10/14/2024 “;Pts (patients) dtr (daughter) expressed dissatisfaction with current hha (home health aide).” The Interdisciplinary group lacks documented evidence in reviewing, revising, and providing the need for volunteer, Hoyer Lift, and aide services. The Visit Note Report documents Left Heel, Unstageable DTI (deep tissue injury):09/17/2024 Epithelialization: <25%; slough: 76-100%; Eschar: 76-100%.10/08/2024 Epithelialization: 75-<100%; Necrotic amount: None. The Hospice IDG (Interdisciplinary group) Comprehensive Assessment and Plan of Care Update Report dated 10/09/2024 documents: “;Patient has bedsore unstageable wound in left heel area, no drainage, no infection.” The Interdisciplinary group lacks documented evidence in reviewing and revising the plan of care with wound improvement and staging of pressure ulcer. The Hospice Certification of Terminal Illness for the Certification Period 09/03/2024 to 12/01/2024 documents: hha (home health aide) 1WK1, 3WK12 (once a week for one week, three times a week for twelve weeks). The Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report dated 09/11/2024, 09/25/2024, and 10/09/2024 documents: No hha (home health aide) service. MLTC (Managed Long Term Care) 7D x 24H. The Duty Sheet by Visit Date documents aide services being provided on 09/09/2024, 09/11/2024, 09/13/2024, 09/18/2024, 09/25/2024, 09/27/2024, 09/30/2024, 10/02/2024, 10/04/2024, 10/07/2024, 10/09/2024, and 10/11/2024. The Interdisciplinary group lacks documented evidence in reviewing and revising the plan of care with aide services being provided by hospice and not with MLTC (Managed Long Term Care). On 10/17/2024 at 02:35pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. *. Patient #12 has a Start of Care date of 04/05/2024 with the following diagnosis “Senile Degeneration of Brain” documented in the Hospice Certification of Terminal Illness for the Certification Period 07/04/2024 to 10/01/2024. The Hospice Recertification Plan of Care Update for the Certification Period 07/04/2024 to 10/01/2024 documents: “;Hospice nurse to perform the following wound care to (pressure ulcer to Sacrum). Utilizing clean technique – Cleanse Stage 3 pressure ulcer with NS (normal saline), pat dry apply MediHoney to wound bed, and Zinc Oxide to periwound cover with Opti Foam and change q (every) shift and PRN (as needed).” The Visit Note Report (Recertification Assessment) dated 06/14/2024 documents: “;Does the patient have active wounds? NO; No additional integumentary assessment findings.” The Visit Note Report dated 07/09/2024, 07/15/2024, 07/23/2024 documents: “;Does the patient have active wounds? NO; Additional Integumentary Observation Findings: No problems identified.” The Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report dated 07/17/2024 and 07/31/2024 lacks documented evidence in reviewing and revising/ discontinuation of the wound order (no wound). The plan of care lacks documented evidence of an accurate order for wound treatment, patient have no pressure ulcer. The Visit Note Report documents: 08/01/2024 Mid Posterior Sacral pressure ulcer stage III. Reactivate wound – recurrence (no measurement or description of wound).08/09/2024 (no measurement or description of wound).08/16/2024 Mid Posterior Sacral pressure ulcer stage III; Epithelialization: 75-<100%; Necrotic Tissue Amount: None.08/21/2024 (no measurement or description of wound).08/27/2024 Mid Posterior Sacral pressure ulcer stage III; Epithelialization: 75-<100%; Necrotic Tissue Amount: None.09/10/2024 Mid Posterior Sacral pressure ulcer stage III; Granulation Tissue: 75-100%; Epithelialization: 100%; Necrotic Tissue Amount: None.09/18/2024 and 09/28/2024 (no measurement or description of wound). The Interdisciplinary group lacks documented evidence in reviewing and revising the wound staging and the progress of the wound every 15 days. On 10/18/2024 at 03:00pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. 3. Patient #20 has a Start of Care date of 7/02/2024 with diagnoses of Chronic Kidney Disease, Stage 5 documented on the Hospice Recertification and Plan of Care with a Certification Period from 9/30/2024 to 12/28/2024. The Routine Visit dated 10/01/2024 documents: “;Skin pale, clean, dry, and intact. Has sacral erythema R/T (related) incontinence. FES (caregiver) washes site with soap and water and applies Zinc Oxide cream daily and PRN (as needed). The Routine Visit dated 10/08/2024 documents: “;Skin pale, clean, dry, and intact. Sacral erythema persists R/T (related) incontinence. FES (caregiver) continues to apply Zinc Oxide cream daily after washing with soap and water to prevent skin brake.” There is no documented evidence of the Physicians Order for medication to be used to sacral erythema. There is no documented evidence of the IDG (Interdisciplinary Group) reviewing and revising the patients individualized plan of care at least every 15 days or as needed that includes medications and treatments. On 10/17/2024 at 02:35pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. *Patient #16 has a Start of Care date of 09/06/2024 with the following diagnoses “Other Sequelae of Cerebral Infarction, Depression, Essential (primary) Hypertension” documented on the Hospice Recertification and Plan of Care for the Certification Period 09/06/2024 to 12/04/2024. The clinical record documents Interdisciplinary Group meetings on 09/11/2024 and 10/02/2024. (greater than 15 days) There is no documented evidence of the Interdisciplinary Group reviewing and revising the Plan of Care at least every 15 calendar days. On 10/17/2024 at 02:35 pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. 1. Patient #1 has a Start of Care date of 07/14/2024 with diagnosis of Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung documented in the “Hospice Certification and Plan of Care” for Certification Period 07/14/2024 to 10/11/2024. The “Hospice Certification and Plan of Care” for Certification Period 07/14/2024 to 10/11/2024 documents: “;Hospice RN (Registered Nurse) to evaluate patient and develop a nursing plan of care in collaboration and in agreement with the patient/representative.” The RN (Registered Nurse) Recertification Assessment “;Visit Note Report” dated 09/20/2024 documents: “;Patient is spending much more time in bed or sitting in his chair and has developed what appears to be a stage two pressure ulcer over coccyx. At time of charting nurse awaiting word from wound care (consult) as to how to address the wound. For the time being patient is using silicone bordered phone (foam) patches to pad area affected and offloading whenever possible.” The NP (Nurse Practitioner) Wound Care Consult Coordination Note dated 09/23/2024 documents: “;Consult Request Date: 9-20-24 Time: 2:04PM;” “;Recommendations/Verbal Order Given: Date 9-20-24 Time: 2:37PM;” “;Received picture of sacral area what appears to be a stage 2 PI (Pressure Injury) from (Skilled Nurse);” “;Recommendations: Wound cleanse, a dab of honey wound gel to the wound, skin prep to protect periwd (periwound), pad with gauze, cover with a silicone foam or composite dsg (dressing) BIW (twice a week) & PRN (as needed), offload;” “;reinforce pressure injury prevention measures as appropriate.” The NP (Nurse Practitioner) Coordination Note documents a verbal order for wound care was given to the Skilled Nurse on 09/20/2024. The “;Hospice IDG (Interdisciplinary) Comprehensive Assessment and Plan of Care Update Report” for meeting date 09/24//2024 and the “;Hospice IDG (Interdisciplinary) Comprehensive Assessment and Plan of Care Update Report” for meeting (Recertification Order) date 10/01/2024 lack documented evidence of the plan of care being reviewed and revised to address the patient’s wound care needs and to include the wound care recommendations/verbal order on 09/20/2024. The clinical record lacks documented evidence of the IDG (Interdisciplinary) Plan of Care being reviewed and revised as frequently as the patients condition of requires. The Hospice Physician Order dated 10/10/2024 (Certification Period 07/14/2024 to 10/11/2024) documents the following wound care order: “;Using Clean technique, cleanse wound with Normal Saline or wound cleanser, apply a dab of medical honey, apply a piece of gauze to wound, apply barrier film to periwound, and cover with silicone foam dressing. Perform wound care biweekly or PRN (as needed). VNS nurses will perform wound care during weekly visit.” The Hospice Recertification Plan of Care Update for Certification Period 10/12/2024 to 01/09/2025 lacks documentation of being updated with the current wound care order to the sacral area. On 10/15/2024 at 1:35PM an observational home visit was conducted with the Skilled Nurse/Registered Nurse. During the home visit, the Skilled Nurse was observed performing wound care on the sacral (coccyx) area. The Skilled Nurse was interviewed regarding the wound care order. The Skilled nurse stated, “;I was following wound care order dated 10/10/2024.” The Skilled nurse showed the surveyor the wound care order dated 10/10/2024 in the patients electronic medical record. The Hospice Physician Order dated 10/16/2024 (Certification Period 10/12/2024 to 01/09/2025) was entered after the home visit and documents: “;Wound with Normal Saline or wound cleanser, apply a dab of medical honey, apply a gauze to wound, apply barrier film to periwound, and cover with silicone foam dressing. Perform wound care biweekly or PRN (as needed). VNS nurses will perform wound care during weekly visit.” There is no documented evidence the Hospice IDG (Interdisciplinary Group) reviewing and revising the patients individualized plan of care to ensure current orders are included to address patients condition. On 10/17/2024 at 2:35pm, the Administrator, the Vice President of Quality, the Directors of Clinical Services/Directors of Patient Services, and staff were interviewed and did not provide an explanation for the survey findings. 2. Patient #3 has a Start of Care date of 09/01/2024 with diagnoses of Malignant Neoplasm of Colon Unspecified, Secondary Malignant Neoplasm of Retroperitoneum and Peritoneum, Constipation Unspecified, Chronic Embolism and Thrombosis of Unspecified Deep Veins of Unspecified Lower Extremity documented in the “Hospice Certification and Plan of Care” for Certification Period 09/01/2024 to 11/29/2024. The “Hospice Certification and Plan of Care” for Certification Period 09/01/2024 to 11/29/2024 documents the following medications: to treat nausea/vomiting - Ondansetron HCL (Hydrochloride) 4mg tablet, 1 tablet 3 times daily prn (as needed) and Hospice Comfort Pak: “;Prochlorperazine (Compazine) 10mg tablet, every 6 hours for nausea, vomiting; and to treat Deep Vein Thrombosis (DVT) – Eliquis (blood thinner) 5mg Tablet, 1 Tablet, every 12 hours. The Coordination Note – Triage RN (Registered Nurse) Call Note dated 10/06/2024 documents the following report of vomiting/symptom management: 10/6/2024 5:52:00PM - the patients primary caregiver “;called to report patient vomiting despite Ondansetron HCL(Hydrochloride) 4mg tablet. Per caller patient has vomited 6 times today. Caller placed on hold to contact NP (Nurse Practitioner);” 10/6/2024 5:56:00PM – Nurse Practitioner said patient “;to take Compazine now and at 10PM then every 4 hours thereafter as needed;” 10/6/2024 5:56:00PM – “;Triage RN (Registered Nurse) relayed NP (Nurse Practitioner) orders to give Compazine (Prochlorperazine) now, at 10PM, and every 4 hours if needed;” and 10/6/2024 6:49:00PM – Outbound call to patients primary caregiver “;to check in on symptoms since taking Compazine. Symptoms have improved and patient is sleeping.” The clinical record lacks documented evidence of an order for Compazine (Prochlorperazine) Every 4 Hours as needed. The Comfort Pak order is “;Prochlorperazine (Compazine) 10mg tablet every 6 hours for nausea, vomiting.” The “;Hospice IDG (Interdisciplinary) Comprehensive Assessment and Plan of Care Update Report” for meeting date 10/08/2024 lacks documented evidence of the plan of care being reviewed and revised with the order to administer Compazine (Prochlorperazine) 4mg Every 4 hours as needed for vomiting. The Coordination Note – Triage RN (Registered Nurse) Call Note dated 10/08/2024 documents another report of vomiting and symptom management: 10/08/2024 2:15:00AM – Patients primary caregiver called to report patient “;has vomited blood three times. (Primary caregiver) gave Ondansetron 4mg at 2135 (9:35PM). (Primary caregiver) is requesting a nurse visit to assess (patient).” The Coordination Note – Missed Visit Notification dated 10/08/2024 documents: the patients primary caregiver “;request to reschedule AHN (After Hour Nurse) visit for the daytime when patient wakes up. PCG (Primary caregiver) verbalized patient is sleeping comfortably and requesting to allow patient to sleep. PCG (Primary caregiver) requesting AM (morning) daytime visit today to evaluate patient vomiting blood tinged drainage. Nurse collaborated with HMD (Hospice Medical Doctor). HMD (Hospice Medical Doctor) ordered the following: Hold Eliquis (blood thinner). Team to follow up with the continued need for Eliquis. PCG (Primary Caregiver) instructed on the same.” The Skilled Nurse/Licensed Practical Nurse “;Visit Note Report” dated 10/08/2024 (11:14AM In-Home Began Time) documents: “;Patient is breathing comfortably on room air with no signs of discomfort noted. Patient complains of episodes of blood in sputum overnight. Covering MD (Medical Doctor) contacted by this nurse. Caregiver advised to continue holding blood thinner for 48 hours. Caregiver express understanding of the same.” The “;Hospice IDG (Interdisciplinary) Comprehensive Assessment and Plan of Care Update Report” for meeting date 10/08/2024 lacks documented evidence of the hospice plan of care being reviewed and revised to include orders to hold Eliquis for 48 hours and to reevaluate patients response after 48 hours. The Interdisciplinary Plan of Care” Policy (Revised May 2020) documents: “;The hospice IDG (Interdisciplinary Group) (in collaboration with the individuals attending physician, if any) reviews, revises and documents the individualized plan as frequently as the patients condition requires, but no less frequently than every 15 calendar days.” The clinical record lacks documented evidence of the IDG (Interdisciplinary) Plan of Care being reviewed and revised as frequently as the patients condition of requires in accordance with the Interdisciplinary Plan of Care” Policy. On 10/17/2024 at 2:35pm, the Administrator, the Vice President of Quality, the Directors of Clinical Services/Directors of Patient Services, and staff were interviewed and did not provide an explanation for the survey findings. 3. Patient #6 has a Start of Care date of 01/08/2024 with diagnosis of Alzheimers Disease documented in the Hospice Certification of Terminal Illness for the Certification Period 09/04/2024 to 11/02/2024. The Hospice Recertification Plan of Care Update for the Certification Period 04/07/2024 to 07/05/2024 documents the following wound care orders: “;Hospice nurse to perform the following wound care (to) Stage 3 Pressure Injury of the Sacrum utilizing clean technique – Cleanse with wound cleanser. Apply Hydrofiber/Aquacel, cover with composite foam dressing, and change 2 times/week and PRN (as needed). Instruct caregiver (name) in (wound) care. Caregiver will provide wound care 1 times/week between nurse visits and PRN (as needed).” The Skilled Nurse/Registered Nurse “;Visit Note Report” dated 06/06/2024 documents: Sacral Pressure Ulcer Stage 3 – Change in Status “;wound resolved (healed).” The Hospice IDG Comprehensive Assessment and Plan of Care Update Report(s) for meeting date 06/18/2024 and 06/25/2024 (Recertification) document: “;healed wounds on sacrum.” The Hospice Recertification Plan of Care Update(s) Order Date 06/14/2024 for Certification Period 07/06/2024 to 09/03/2024 and 08/20/2024 Order for Certification period 09/04/2024 to 11/02/2024 continue to document wound care orders for Stage 3 Pressure Injury of sacrum. The IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report(s) lack documented evidence of the Interdisciplinary Group reviewing and revising the hospice plan of care to discontinue wound care order to the sacrum. On 10/21/2024 at 12:15pm, the Administrator, the Vice President of Quality, the Director of Clinical Services/Director of Patient Services, and staff were interviewed and did not provide an explanation for the survey findings.”

“Based on clinical care record reviews and staff interviews, the agency failed to ensure adequate supervision of the nursing services. This was evident for one (1) of thirty (30) clinical records reviewed. (Patients #3). Failure to ensure that adequate supervision of the nursing services, has the potential for negative patient outcomes. The Findings Are: 1. Patient #3 has a Start of Care date of 09/01/2024 with diagnoses of Malignant Neoplasm of Colon Unspecified, Secondary Malignant Neoplasm of Retroperitoneum and Peritoneum, Constipation Unspecified, Chronic Embolism and Thrombosis of Unspecified Deep Veins of Unspecified Lower Extremity documented in the “Hospice Certification and Plan of Care” for Certification Period 09/01/2024 to 11/29/2024. The Skilled Nurse/Registered Nurse “;Visit Note Report” dated 10/02/2024 documents: respiratory assessment findings - “;no abnormal respiratory findings identified.” The Skilled Nurse/Licensed Practical Nurse “;Visit Note Report” dated 10/08/2024 documents: respiratory assessment findings - “;use of accessory muscles.” The clinical record lacks documented evidence of the Licensed Practical Nurse reporting the respiratory findings and the Registered Nurse reviewing the Licensed Practical Nurse ‘s findings to ensure the provision of appropriate care. On 10/17/2024 at 2:35PM the Administrators/the Directors of Clinical Services/Directors of Patient Services, (Senior Vice President Hospice and Palliative Care, Vice President Clinical Operations) and staff were interviewed and did not provide an explanation for the survey finding.”

“Based on clinical record reviews and staff interview, the hospice failed to ensure all Hospice Aides receive complete written patient care instructions. This was evident for nine (9) of thirty (30) clinical records reviewed. (Patients #1, #7, #10, #11, #12, #16, #17, #22, and #25). Failure to ensure all Hospice Aides receive complete written patient care instructions, has the potential for negative patient outcomes. The Findings Are: *. Patient #22 has a Start of Care date 9/06/2024 with a diagnosis of Malignant Neoplasm of Prostate documented on the Hospice Certification and Plan of Care with a Certification Period from 9/06/2024 to 12/04/2024. The Hospice Certification and Plan of Care with a Certification Period from 9/06/2024 to 12/04/2024 documents: “;Hospice Nurse to insert/maintain indwelling catheter ... change catheter as needed for infection, obstruction or when the closed system is compromised. Hospice Nurse to coordinate Plan of Care with facility staff.” The Client Episode Coordination Note Report dated 9/20/2024 documents: “;Call Note: Caller: Name (son). Request: to confirm POC (Plan of Care) for pt (patient). Call Note: states that HHA (Home Health Aide) did not want to take pt (patient) out or change catheter bag – Please call back.” The Hospice Home Health Aide Plan of Care from 9/06/2024 to 12/04/2024 lacks documented evidence of the instructions for the aide to change the catheter bag and aide observations that should be reported to the supervisor. There is no documented evidence of an accurate written patient care instructions for a hospice aide to follow. On 10/17/2024 at 02:35pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. *Patient #16 has a Start of Care date of 09/06/2024 with the following diagnoses “Other Sequelae of Cerebral Infarction, Essential (Primary) Hypertension, Depression” documented on the Hospice Recertification Plan of Care Update for the Certification Period 09/06/2024 to 12/04/2024. The Hospice Recertification Plan of Care Update for the Certification Period 09/06/2024 to 12/04/2024 documents: “HHA (home health aide) effective 09/08/2024 5 WK 12 (five times a week for twelve weeks), 3 WK 1(three times per week for one week); DME (durable medical equipment) and Supplies: O2 (oxygen) Home Setups; Safety Measures: O2 Precautions, Fall Precautions; Nutritional Requirements: Pureed, Thin Liquid, Comfort Feeding”. The Aide Plan of Care Report dated 09/06/2024 lacks documented evidence of DME (durable medical equipment) and Supplies - O2 (oxygen) home, Safety Measures - O2 (oxygen) Precautions for oxygen, Fall Precautions and Nutritional Requirements/diet. There is no documented evidence of a complete Aide’s Plan of Care. On 10/18/2024 at 02:35pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. *Patient #17 has a Start of Care date of 07/03/2024 with the following diagnoses “Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Gastro-Esophageal Reflux Disease” documented on the Hospice Recertification Plan of Care Update for the Certification Period 10/01/2024 to 12/29/2024. The Hospice Recertification Plan of Care Update for the Certification Period 10/01/2024 to 12/29/2024 documents: “HHA (home health aide) effective 10/01/2024 4 WK 1(four times per week for one week), 6 WK 12 (six times per week for twelve weeks), 1 WK 1(once a week for one week); Medications: Current O2-Oxygen Start Date: 07/05/2024” The Aide Plan of Care Report dated 10/01/2024 lacks documented evidence of DME (durable medical equipment) and Supplies - O2 (oxygen) home, Safety Measures - O2 (oxygen) Precautions for oxygen use and diet. There is no documented evidence of a complete Aide’s Plan of Care. On 10/18/2024 at 02:35pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. *. Patient #7 has a Start of Care date of 08/22/2024 with the following diagnosis “Diffuse Large B-Cell Lymphoma” documented in the Hospice Certification and Plan of Care for the Certification Period 08/22/2024 to 11/19/2024. The Hospice Certification and Plan of Care for the Certification Period 08/22/2024 to 11/19/2024 documents: hha (home health aide) effective 08/25/2024 1WK12 (once a week for twelve weeks); DME (durable medical equipment): wheelchair. The Visit Note Report dated 08/22/2024 documents: Existing equipment / supplies owned by patient: cane, walker, shower stool. The Aide Plan of Care Report dated 08/22/2024 lacks documented evidence of the diet; DME (durable medical equipment) – wheelchair, walker, cane, shower stool; and instructions of aide observations that should be reported to the supervisor. There is no documented evidence of an accurate written patient care instructions for a hospice aide to follow. On 10/17/2024 at 02:35pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. *. Patient #10 has a Start of Care date of 09/03/2024 with the following diagnoses “Alzheimers Disease, Dementia” documented in the Hospice Certification of Terminal Illness for the Certification Period 09/03/2024 to 12/01/2024. The Hospice Certification of Terminal Illness for the Certification Period 09/03/2024 to 12/01/2024 documents: hha (home health aide) 1WK1, 3WK12 (once a week for one week, three times a week for twelve weeks), Nutritional Requirements: soft thin liquids. The Visit Note Report dated 09/03/2024 documents: Existing equipment / supplies owned by patient: hospital bed, walker. The Aide Plan of Care Report dated 09/03/2024 lacks documented evidence of the diet; DME (durable medical equipment) – hospital bed, walker; and instructions of aide observations that should be reported to the supervisor. There is no documented evidence of an accurate written patient care instructions for a hospice aide to follow. On 10/17/2024 at 02:35pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. *. Patient #11 has a Start of Care date of 09/09/2024 with the following diagnoses “Malignant Neoplasm of Ovary, Anxiety Disorder” documented in the Hospice Certification and Plan of Care for the Certification Period 09/09/2024 to 12/07/2024. The Hospice Certification and Plan of Care for the Certification Period 09/09/2024 to 12/07/2024 documents: hha (home health aide) 4WK1, 5WK12 (four times a week for one week, five times a week for twelve weeks), Allergies: Shellfish, Dermabond, Doxycycline, Tetracycline. The Aide Plan of Care Report dated 09/09/2024 lacks documented evidence of the allergies and instructions of aide observations that should be reported to the supervisor. There is no documented evidence of an accurate written patient care instructions for a hospice aide to follow. On 10/18/2024 at 03:00pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. *. Patient #12 has a Start of Care date of 04/05/2024 with the following diagnosis “Senile Degeneration of Brain” documented in the Hospice Certification of Terminal Illness for the Certification Period 07/04/2024 to 10/01/2024. The Hospice Recertification Plan of Care Update for the Certification Period 07/04/2024 to 10/01/2024 documents: hha (home health aide) frequency 5days x 2hours, DME (durable medical equipment) – hospital bed. The Visit Note Report (Recertification Assessment) dated 06/14/2024 documents: Pt (patient) requires Hoyer Lift with 2 persons assist daily, shes OOB (out of bed) to Geri chair daily as tolerated. The Aide Plan of Care Report dated 07/04/2024 lacks documented evidence of the DME (durable medical equipment): Hoyer Lift and Gerichair; and instructions of aide observations that should be reported to the supervisor. There is no documented evidence of an accurate written patient care instructions for a hospice aide to follow. On 10/18/2024 at 03:00pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. *. Patient #25 has a Start of Care date of 01/09/2024 and a discharge date of 01/30/2024 with the following diagnoses “Heart Failure, Vascular Dementia” documented in the Hospice Certification and Plan of Care for the Certification Period 01/09/2024 to 04/07/2024. The Hospice Certification and Plan of Care for the Certification Period 01/09/2024 to 04/07/2024 documents: hha (home health aide) 2WK1, 5WK12 (twice a week for one week, five times a week for twelve weeks; Allergies: Sulfa. The Aide Plan of Care Report dated 01/12/2024 lacks documented evidence of the allergies and instructions of aide observations that should be reported to the supervisor. There is no documented evidence of an accurate written patient care instructions for a hospice aide to follow. On 10/18/2024 at 03:00pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. 1. Patient #1 has a Start of Care date of 07/14/2024 with diagnosis of Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung documented in the “Hospice Certification and Plan of Care” for Certification Period 07/14/2024 to 10/11/2024. The “Hospice Certification and Plan of Care” for Certification Period 07/14/2024 to 10/11/2024 documents: “;Home Health Aide service for assistance with personal care, hygiene and activities of daily living. (Home Health Aide) frequency 5Daysx2Hours (five days a week times two hours a day), Monday-Friday.” The Coordination note dated 07/15/2024 documents: “;TC (Telephone call) on 7/15/24 @ 5:32pm with pts (patients) (spouse) informing (spouse) that pts (patients) SOC (aide start of care) is effective as of 7/16/24-7/17/24, Mon-Fri, 2 hours. Pts (Patients) (spouse) requested aide to come in between 8-10 or 9-11am. Let (spouse) know that (home health aide) is scheduled for Wed 7/17/24 from 9-11;” “;(spouse) requested to cancel services for 7/16/24 but resume for 7/17/24 instead.” The Coordination Note dated 07/17/2024 documents: “;Time of Call: 7/17/2024 9:47AM;” “;Pt (Patient) spouse stated the aide is refusing to assist with pt (patient) until (aide) obtains a POC (plan of care). (Patients spouse) also stated no nurse has come out as yet;” “;Action Taken: T/C (Telephone call) placed to the nurse (name). As per (nurse), (nurse) will be there between 11-11:30am. (Spouse) was informed & agreed.” The Skilled Nurse/Registered Nurse “;Visit Note Report” dated 07/17/2024 documents the following the supervision of the aide: “;Were supervisory functions performed? No;” and “;Indicate Other reason supervisory function not performed: (Home Health Aide) ended shift.” There is no documented evidence of the registered nurse providing written patient care instructions (aide plan of care) for the Home Health Aide (Hospice Aide) at the start of aide services. On 10/17/2024 at 2:35pm, the Administrator, the Vice President of Quality, the Directors of Clinical Services/Directors of Patient Services, and staff were interviewed and did not provide an explanation for the survey finding.”

“Based on clinical record review and staff interview, the hospice failed to ensure hospice aide supervisory visits are conducted every 14 days. This was evident for four (4) of thirty (30) clinical records reviewed. (Patients #1, #7, #14, and #25). Failure to ensure hospice aide supervisory visits are conducted every 14 days, has the potential for negative patient outcomes. The Findings Are: 4. Patient #14 has a Start of Care date of 10/27/2023 with the following diagnoses “Malignant Neoplasm of Prostate, Vascular Dementia, Dysphagia” documented on the Hospice Recertification Plan of Care Update for the Certification Period 08/22/2024 to 10/20/2024. The Hospice Recertification Plan of Care Update for the Certification Period 08/22/2024 to 10/20/2024 documents: “HHA (home health aide) effective 08/25/2024 5 WK 8 (five times per week for eight weeks). The Duty Sheet by Visit Date documents aide services being provided from 09/26/2024 to 10/17/2024. The clinical record lacks documented evidence of home health aide supervision from 09/26/2024 to 10/15/2024. (greater than 14 days) The clinical record lacks documented evidence of home health aide supervision every (14) fourteen days. On 10/17/2024 at 02:35 pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. 2. Patient #7 has a Start of Care date of 08/22/2024 with the following diagnosis “Diffuse Large B-Cell Lymphoma” documented in the Hospice Certification and Plan of Care for the Certification Period 08/22/2024 to 11/19/2024. The Hospice Certification and Plan of Care for the Certification Period 08/22/2024 to 11/19/2024 documents: hha (home health aide) effective 08/25/2024 1WK12 (once a week for twelve weeks). The Visit Calendar documents aide services being provided on 09/12/2024, 09/19/2024, 09/26/2024, 10/03/2024, and 10/10/2024. The clinical record documents aide supervision completed on 09/12/2024, and 10/04/2024. The clinical record lacks documented evidence of aide supervision every 14 days. On 10/17/2024 at 02:35pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. 3. Patient #25 has a Start of Care date of 01/09/2024 and a discharge date of 01/30/2024 with the following diagnoses “Heart Failure, Vascular Dementia” documented in the Hospice Certification and Plan of Care for the Certification Period 01/09/2024 to 04/07/2024. The Hospice Certification and Plan of Care for the Certification Period 01/09/2024 to 04/07/2024 documents: hha (home health aide) 2WK1, 5WK12 (twice a week for one week, five times a week for twelve weeks; Allergies: Sulfa. The Duty Sheet by Visit Date documents aide services being provided on 01/20/2024, 01/27/2024, and 01/28/2024. The clinical record lacks documented evidence of aide supervision. On 10/18/2024 at 03:00pm, the Administrators/Directors of Clinical Services/ Directors of Patient Services and staff were interviewed and did not provide an explanation for the findings. 1. Patient #1 has a Start of Care date of 07/14/2024 with diagnosis of Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung documented in the “Hospice Certification and Plan of Care” for Certification Period 07/14/2024 to 10/11/2024. The “Hospice Certification and Plan of Care” for Certification Period 07/14/2024 to 10/11/2024 documents: “Home Health Aide service for assistance with personal care, hygiene and activities of daily living. (Home Health Aide) frequency 5Daysx2Hours (five days a week times two hours a day), Monday-Friday.” The Coordination note dated 07/15/2024 documents: “;TC (Telephone call) on 7/15/24 @ 5:32pm with pts (patients) (spouse) informing (spouse) that pts (patients) SOC (aide start of care) is effective as of 7/16/24-7/17/24, Mon-Fri, 2 hours. Pts (Patients) (spouse) requested aide to come in between 8-10 or 9-11am. Let (spouse) know that (home health aide) is scheduled for Wed 7/17/24 from 9-11.” The Coordination Note dated 07/17/2024 documents: “;Time of Call: 7/17/2024 9:47AM;” “;Pt (Patient) spouse stated the aide is refusing to assist with pt (patient) until (aide) obtains a POC (plan of care). (Patients spouse) also stated no nurse has come out as yet;” “;Action Taken: T/C (Telephone call) placed to the nurse (name). As per (nurse), (nurse) will be there between 11-11:30am. (Spouse) was informed & agreed.” The Skilled Nurse/Registered Nurse “;Visit Note Report” dated 07/17/2024 documents the following response to the supervision of the aide: “;Were supervisory functions performed? NO;” “;Indicate other reason supervisory functions not performed: (Home Health Aide) has already ended shift.” There is no documented evidence of the registered nurse ensuring the home health aide (hospice aide) are adequately supervised, and that hospice aide furnished care to meet the patients needs at the start of aide services. On 10/17/2024 at 2:35pm, the Administrator, the Vice President of Quality, the Directors of Clinical Services/Directors of Patient Services, and staff were interviewed and did not provide an explanation for the survey finding.”

“Based on clinical record reviews and staff interviews, the hospice failed to ensure that Nursing services are provided according to the plan of care. This was evident for one (1) of four (4) clinical records reviewed (Patient #1). Failure to provide services according to the plan of care has the potential for negative patient outcomes. The findings are: 1. Patient #1 has Start of Care date of 4/25/2024 and a discharge date of 04/28/2024, with the following diagnoses of “;Alzheimers disease, Dysphagia, Acute Kidney Failure, Pressure Ulcer of Right Buttock, Stage 1, and Pressure Ulcer of Left Buttock, Stage 1,” documented on the Hospice Certification and Plan of Care with a certification period from 4/25/24 to 7/23/24. The Hospice Certification and Plan of Care (medical orders) with a Certification Period from 4/25/24 to 7/23/24 documents orders for “;SN 2WK1, 1WK13, 6PRN for Symptom Management,” (Skilled Nursing two times a week for one week, then one times a week for 13 weeks, and six as needed for symptom management). The Hospices work week is Sunday through Saturday. The clinical record documents the Hospice RN (Registered Nurse) conducting an initial nursing visit on 4/25/24 during the first work week from Sunday, 4/21/24 to Saturday, 4/27/24. There is no documented evidence of a second nursing visit during the first work week from Sunday, 4/21/24 to Saturday, 4/27/24, as ordered. On 8/16/24 at 1:00 pm, the Vice President of Clinical Operations and Vice President Quality were interviewed and did not provide an explanation for the findings.”

“Based on clinical record reviews and staff interviews, the hospice licensed professionals failed to coordinate all aspects of the patients hospice care with the patients family. This was evident for one (1) of four (4) clinical records reviewed (Patient #1). Failure to coordinate all aspects of a patients care with the patients family has the potential for negative patient outcomes. The findings are: 1. Patient #1 has Start of Care date of 4/25/2024 and a discharge date of 04/28/2024, with the following diagnoses of “;Alzheimers disease, Dysphagia, Acute Kidney Failure, Pressure Ulcer of Right Buttock, Stage 1, and Pressure Ulcer of Left Buttock, Stage 1,” documented on the Hospice Certification and Plan of Care with a certification period from 4/25/24 to 7/23/24. The “Hospice -Liaison Daily Update” note dated 4/25/24 documents, “;Email received from PTS HCP (patients Health Care Proxy) (name of health care proxy) regarding a missed call from the ARN (Admitting Registered Nurse) and follow up care of PT (patient). I referred this to (name of Hospice employee) and Admission Registered Nurse to follow up with Health Care Proxy.” There is no documented evidence of the Admitting RN following up with health care proxy about the patients care. The “;Hospice- CCC/AH (Customer Call Center/After Hours) Urgent Clinical (ASAP F/UP Needed),” (As Soon As Possible Follow UP Needed) note dated 4/27/24 documents, “;Note: Call Start Time: 4/27/24, 4:20 pm. Caller Name (name of Health Care Proxy) . . . . . Request: patient inquiry. Call Notes nurse was here on Thursday to evaluate the patient. Caller wants to know when services is going to start. Action Taken: message conveyed to team . . . . “; There is no documented evidence of the hospice returning the health care proxys phone call requesting to find out about the start of the patients hospice services. On 8/16/24 at 11:30 am, the Vice President of Clinical Operations and Vice President Quality were interviewed. The Vice President of Clinical Operations stated, “;We found out the call center (representative) who escalated the call closed the call so it never got to a supervisor. “; The Vice President of Quality stated, “;We interviewed the nurse and she does not have anything (follow up email or call to the health care proxy).””

“Based on clinical care record review and staff interviews, the governing authority failed to ensure nursing needs of the patient are met as identified in the assessments. This was evident for one (1) of three (3) patient care records reviewed (Patient #1). Failure to ensure nursing needs of the patient are met as identified in the assessments has the potential for negative patient outcomes. The findings are: The NPIAP (National Pressure Injury Advisory Panel) Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Guidelines for 2019 documents: Pressure injuries are painful. Individuals with pressure injuries experience wound-related pain that can be quantified and differentiated from other pain, and this pain occurs both during procedures and at rest. 1. Patient #1 has a Start of Care date of 12/14/2023 and a discharge date (expired) of 12/26/2023, with the following diagnoses “Alzheimers Disease, Dementia, Dysphagia” documented in the Hospice Certification and Plan of Care dated 12/14/2023 to 03/12/2024. The Hospice Certification and Plan of Care dated 12/14/2023 to 03/12/2024 documents: Pressure Ulcers on Right Buttock at Stage III, Left Buttocks at Stage III, and Right Heel DTI (deep tissue injury). Medication: Acetaminophen 325 mg (milligram) 2 tablet every 6 hours PRN (as needed). Goals: Wound will be managed without infection and pain will be controlled. The Visit Note Report dated 12/14/2023 documents: Patients Mental Status: Disoriented, confused, lethargic; Type of standardized pain tool used: Staff observation; Indicate what makes pain worse: procedures or treatments; Communicate a choice: Patient cannot make a choice and provides no logical reasoning; minimally verbal. The clinical record documents hospice nurse assessment on 12/14/2023, 12/15/2023, and 12/20/2023 patient have no pain and wound care was done by facility nurse. There is no documented evidence of the pain assessment during dressing change. There is no documented evidence of a complete assessment to ensure that the needs of the patient are met. On 06/14/2024 at 3:09pm, the Vice President was interviewed and did not provide an explanation for the findings.”

“Based on clinical care record review and staff interviews, the governing authority failed to ensure that the supervising nurse must assess an aides ability to demonstrate initial satisfactory performance. This was evident for one (1) of three (3) patient care records reviewed (Patient #1). Failure to ensure that the supervising nurse must assess an aides ability to demonstrate initial satisfactory performance has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a Start of Care date of 12/14/2023 and a discharge date (expired) of 12/26/2023,with the following diagnoses “Alzheimers Disease, Dementia, Dysphagia” documented in the Hospice Certification and Plan of Care dated 12/14/2023 to 03/12/2024. The Hospice Certification and Plan of Care dated 12/14/2023 to 03/12/2024 documents: “;hha (home health aide) 1WK1, 5WK12 (once a week for one week, five times a week for twelve weeks).” The Aide Duty Sheet documents aide providing services on 12/15/2023, 12/18/2023 to 12/22/2023, and 12/25/2023. There is no documented evidence of an initial nursing supervision to assess an aides ability and satisfactory performance. On 06/14/2024 at 3:09pm, the Vice President was interviewed and did not provide an explanation for the findings.”

“Based on clinical care record review and staff interviews, the governing authority failed to ensure a physician order. This was evident for one (1) of three (3) patient care records reviewed (Patient #1). Failure to ensure a physician order has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a Start of Care date of 12/14/2023 and a discharge date (expired) of 12/26/2023, with the following diagnoses “Alzheimers Disease, Dementia, Dysphagia” documented in the Hospice Certification and Plan of Care dated 12/14/2023 to 03/12/2024. The Hospice Certification and Plan of Care dated 12/14/2023 to 03/12/2024 documents: Nutritional Requirements: Puree diet, thin liquids. The Client Episode Coordination Notes Report dated 12/20/2023 documents: “;RN (registered nurse) collaborate with facility (name of physician) on patient coughing while eating. She ordered speech and swallow test and changes to patients diet.” The Order Listing (from the nursing home) printed on 06/14/2024 documents: Regular diet, puree level 4 texture. Moderate Thick (formerly Nectar) Level 3 consistency (liquids), start date 12/20/2023. There is no documented evidence of the physician order on the changed of diet. On 06/14/2024 at 3:30pm, the Vice President and the Assistant Vice President were interviewed and did not provide an explanation for the findings.”

“Based on clinical care record review and staff interviews, the governing authority failed to ensure that the SNF (skilled nursing facility) immediately notifies the hospice that suggest a need to alter the plan of care. This was evident for one (1) of three (3) patient care records reviewed (Patient #1). Failure to ensure that SNF (skilled nursing facility) immediately notifies the hospice that suggest a need to alter the plan of care has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a Start of Care date of 12/14/2023 and a discharge date (expired) of 12/26/2023, with the following diagnoses “Alzheimers Disease, Dementia, Dysphagia” documented in the Hospice Certification and Plan of Care dated 12/14/2023 to 03/12/2024. The Hospice Certification and Plan of Care dated 12/14/2023 to 03/12/2024 documents: “;Nutritional Requirements: Puree diet, thin liquids.” The Aide Care Plan Report dated 12/14/2023 documents: “;ADL (activities of daily living) services: Feed patient five times a week; Pureed/ thin liquids.” The Order Listing (from the nursing home) printed on 06/14/2024 documents: Ceftriaxone Sodium Solution, use 1 gram intravenously every 24 hours for pneumonia for 5 days, start date 12/24/2023.Regular diet, puree level 4 texture. Moderate Thick (formerly Nectar) Level 3 consistency (liquids), start date 12/20/2023. There is no documented evidence of the SNF (skilled nursing facility) immediately notifying the hospice of the diet change and new diagnosis of pneumonia – placed on intravenous antibiotic, to alter the hospice plan of care and aides instructions. On 06/14/2024 at 3:09pm, the Vice President was interviewed and did not provide an explanation for the findings.”