M J H S Hospice and Palliative Care, Inc.

“Based on record review and staff interviews, the hospice agency failed to ensure that the Interdisciplinary Group reviews and revises the plan of care to address changes in patient’s condition and needs as identified in the comprehensive assessment, in accordance with hospice policies and procedures. This was evident for one (1) of three (3) clinical record reviews (Patient #1). Failure to ensure that the Interdisciplinary Group reviews and revises the plan of care to address changes in patient’s condition and needs, as identified in the comprehensive assessment, has the potential for negative patient outcomes. The finding is: 1. Patient #1 has a start of care date of 03/19/2024, Discharge Date of 03/14/2025 with diagnosis of Senile Degeneration of Brain documented in the “Physician’s Orders/Plan of Care” for the Benefit Period 03/14/2025 to 05/12/2025. The “Physician’s Orders/Plan(s) of Care” for the Benefit Periods 11/14/2024 to 01/12/2025, 01/13/2025 to 03/13/2025 document that the patient is to receive Skilled Nurse visits one to three times a week. The Registered Nurse/Skilled Nurse comprehensive visit note dated 12/03/2024 documents the patient has “a new wound” on the left upper back. The Registered Nurse documents the following wound assessment: wound type lesion, wound tissue beefy red, measurement 2 cm (centimeters) x 1cm, surrounding skin intact, no drainage. The Registered Nurse documents: “wound care instructions were given during visit.” The subsequent weekly Registered Nurse/Skilled Nurse comprehensive visit notes dated 12/10/2024, 12/17/2024, 12/24/2024 (Recertification), 12/31/2024, 01/07/2025, 01/14/2025, 01/21/2025, 01/31/2025, 02/04/2025, 02/11/2025, /03/04/2025 (Recertification) and 03/11/2025 document: weekly wound assessment of left upper back lesion, “not healing;” and “Dressing changed this visit: Yes, per order, see Care Plan.” The “RNCM (Registered Nurse Case Manager) Visit/Recert Visit” Clinical Update/ Progress notes dated and sent to the Hospice Physician on 12/24/2024 and 03/04/2025 document: the visit summary and Hospice Physician “made a telehealth visit during this time.” The MD (Medical Doctor) Face-to-Face Encounter” telehealth visits dated 12/24/2024 and 03/04/2025 lack documentation of the left upper back lesion. The clinical record lacks documentation of wound care orders/instructions to address the left upper back lesion. The “Wound Care Assessment” Policy (Approved 06/21/2024) documents: The nursing staff “documents an individualized plan for each patient with a wound based on the physician’s orders, patient’s needs, and plan of care goals” “wounds are discussed in the Interdisciplinary Team (IDT) meeting;” “A wound care specialist is available to Hospice for consultation as determined by the IDT (Interdisciplinary Team). A WOCN wound care consult is initiated by the RNCM (Registered Nurse Case Manager).” The “IDT (Interdisciplinary Team) Plan of Care” Policy (Approved 11/23/2023) documents: “The Plan of Care is routinely reviewed by the IDT (Interdisciplinary Team) as frequently as the patient’s condition requires, but no less frequently than every 15 days.” The “IDT (Interdisciplinary Team) Assessment(s)” dated 12/05/2024, 12/19/2024, 01/02/2025, 01/16/2025, 01/30/2025. 02/13/2025, 02/27/2025, 03/13/2025 documents in the Plan of Care Changes section: “Are there any changes to the patient’s condition or Plan of Care (in any clinical area) since the last IDT (Interdisciplinary Team):” “No change to the patient’s condition. Patient is managed with the current Plan of Care.” The clinical record lacks documented evidence of Interdisciplinary Team discussing, reviewing and revising the plan of care, in accordance with hospice policies and procedures, to address the new wound identified in the comprehensive assessment on 12/03/2024. On 05/20/2025 at 3:55pm, the Registered Nurse Case Manager was interviewed and stated: the wound care order was “cleanse with Normal Saline, pat dry, and apply foam dressing;” “I don’t see that (order) there” in the record; the physician was made aware in December; I told physician “what (wound care) I did;” the wound was discussed in IDT(Interdisciplinary Team); it’s “not documented,” “I didn’t see any changes in the wound.” On 05/20/2025 at 3:55pm, the Hospice Physician was interviewed and stated: “I told the nurse to monitor” the lesion; I saw pictures of the lesion in March; “typically, I make a change in an order” for wound treatment; “no treatment” was ordered. On 05/21/2025 at 11:20am, the Chief Medical Offer/Medical Director, the Senior Vice President/Administrator/Director of Patient Services, the Chief Operating Officer, and the Assistant Vice President were interviewed about the finding and no additional evidence was provided.”

“Based on record review and staff interviews, the hospice failed to ensure a system of communication and integration was implemented according to the hospice policies and procedures and that care and services are provided in accordance with a written plan of care to address the patient wound care needs. This was evidence in one (1) of three (3) clinical record reviews (Patient #1). Failure to ensure a system of communication and integration and the provision of care and services in accordance with a plan of care has the potential for negative patient outcomes. The finding is: 1. Patient #1 has a start of care date of 03/19/2024, Discharge Date of 03/14/2025 with diagnosis of Senile Degeneration of Brain documented in the “Physician’s Orders/Plan of Care” for the Benefit Period 03/14/2025 to 05/12/2025. The “Physician’s Orders/Plan(s) of Care” for the Benefit Periods 11/14/2024 to 01/12/2025, 01/13/2025 to 03/13/2025 document that the patient is to receive Skilled Nurse visits one to three times a week. The Registered Nurse/Skilled Nurse comprehensive visit note dated 12/03/2024 documents the patient has “a new wound” on the left upper back. The Registered Nurse documents the following wound assessment: “wound type lesion, wound tissue beefy red, measurement 2 cm (centimeters) x 1cm, surrounding skin intact, no drainage”. The Registered Nurse documents: “wound care instructions were given during visit.” The subsequent weekly Registered Nurse/Skilled Nurse comprehensive visit notes dated 12/10/2024, 12/17/2024, 12/24/2024 (Recertification), 12/31/2024, 01/07/2025, 01/14/2025, 01/21/2025, 01/31/2025, 02/04/2025, 02/11/2025, /03/04/2025 (Recertification) and 03/11/2025 document: “weekly wound assessment of left upper back lesion”, “not healing;” and “Dressing changed this visit: Yes, per order, see Care Plan.” The “IDT (Interdisciplinary Team) Plan of Care” Policy (Approved 11/23/2023) documents: “Ongoing communication among IDT (Interdisciplinary Team) members is essential for quality care. Documentation of all communication pertinent to the plan of care will be reflected in the clinical record.” The “Wound Care Assessment” Policy (Approved 06/21/2024) documents: “Hospice Physician or designee is notified of newly developed wounds.” The clinical record lacks documented evidence of the Registered Nurse Case Manager notifying the Hospice Physician of the new wound on the left upper back and obtaining wound care instructions/orders to revise the plan of care. There is no documented evidence of communication between the Registered Nurse and the Hospice Physician regarding wound care instructions. On 05/20/2025 at 3:55pm, the Registered Nurse Case Manager was interviewed and stated: the physician was made aware in December; I told the physician “what (wound care) I did;” the wound care was “cleanse with Normal Saline, pat dry, and apply foam dressing;” “I didn’t see any changes in the wound.” On 05/20/2025 at 3:55pm, the Hospice Physician was interviewed and stated: “I told the nurse to monitor” and “no treatment” was ordered for the lesion. On 05/21/2025 at 11:20am, the Chief Medical Offer/Medical Director, the Senior Vice President/Administrator/Director of Patient Services, the Chief Operating Officer, and the Assistant Vice President were interviewed regarding the findings and the Chief Operating Officer present an email explanation from the Hospice Physician. The email dated 05/21/2025 documents: “The skin finding on (Patient #1’s) back was a lesion in my medical judgement, not a wound that that required active treatment.” “I determined that observation of the lesion was the appropriate management, and my instructions to the RNCM (Registered Nurse Case Manager) were to monitor the lesion for changes and instruct family to do the same. No treatment orders were required.” “The physician’s verbal communication with the nursing staff, including instructions regarding routine patient care and standard orders, are documented by the nurse.”The clinical record lacks documentation of communication from the Hospice Physician to the RNCM (Registered Nurse Case Manager) with instructions to monitor the lesion and that no treatment orders were required, in accordance with the IDT Plan of care Policy to document all communication pertinent to the plan of care.”

“Based on clinical record reviews, policy and procedures review, and staff interviews, the Hospice failed to ensure the hospice nurses and Interdisciplinary Group (IDG) members are performing complete and updated comprehensive assessments, that the hospice nurses are communicating changes in the patient’s condition that are consistent with the comprehensive assessment findings to the IDG. This was evident for two (2) of twenty-seven (27) clinical records reviewed (Patient #8 and #27). Failure to ensure the hospice nurses and Interdisciplinary Group (IDG) members are performing complete and updated comprehensive assessments that reflect accurate changes in the status of the patient has the potential for negative patient outcome. The findings are: 2.Patient #27 has a Start of Care date of 01/16/2024 with the following diagnoses: “Hemiparesis Affecting Left Side As Late Effect of Cerebrovascular Accident (CVA), Dyspnea, Dependence of Supplemental Oxygen, Bedbound, Pain, Weakness, Lethargy” documented in the Physician’s Orders/Plan of Care dated 03/16/2024 to 05/14/2024. The Physician’s Orders/Plan of Care dated 03/16/2024 to 05/14/2024 documents Skilled Nursing (SN) wound orders: “;Sacral wound (pressure ulcer) clean with NSS (normal saline solution) or soap and water, apply foam bordered dressing every 3-4 days and prn (as needed) if soiled. (Family member) and private caregiver instructed;” “;left ear tiny unstageable (pressure ulcer), leave open to air, keep off the sheets;” and goal/expected outcomes: “;Pressure ulcers will be prevented/healed when feasible, existing pressure ulcers will not worsen.” The SN (Skilled Nurse) Visit Note dated 4/3/2024 documents: Pressure Ulcer Stage 2 “;Sacral wound closed however (family member) still wants foam dressing on for protection.” The IDT (Interdisciplinary Team) Assessments dated 03/26/2024, 04/09/2024, and 04/23/2024 lack documented evidence of including an update of the sacral pressure ulcer status as healed, and the patient familys request to continue the foam dressing for protection. The IDT Assessments dated 03/26/2024, 04/09/2024, and 04/23/2024 lack documented evidence of an update and the healing progress/status of the left ear unstageable pressure ulcer. There is no documented evidence of the IDT (Interdisciplinary Team) Assessment being updated every 15 days with information on the status and progress of the patient’s left ear unstageable pressure ulcer. The Hospices “;Pain Management” policy documents: “;Reassessing the patients pain: Providers routinely assess effectiveness of the pain management plan of care and document and report findings with the interdisciplinary team at the IDT (Interdisciplinary Team) meeting, and as needed.” The IDT (Interdisciplinary Team) Assessments dated 04/09/2024 and 04/23/2024 lack documented evidence of a report/update on the patients pain management/control and the effectiveness of the current pain regimen. The IDT assessments lack documented evidence of being updated to reflect the most recent changes in the patients status and needs. On 05/03/2024 at 1:45pm, the Associate Vice President of Hospice Clinical Services, the Clinical Director, the Chief Operating Officer, the Director of Quality Management, and the Senior Vice President of Business Development were interviewed and did not provide and explanation for the findings. 1.Patient #8 has a Start of Care date of 03/20/2023 with the following diagnoses “Alzheimers Dementia, Dementia Associated with Other Underlying Disease with Anxiety” documented in the Physicians Orders/Plan of Care dated 03/14/2024 to 05/12/2024. The Physicians Orders/Plan of Care dated 03/14/2024 to 05/12/2024 documents: “Nystatin 100 000 U/GM TID (unit per gram three times a day) sacral fungal infection.” The Medication List as of 04/29/2024 documents “;Nystatin External Powder; one application t.i.d. (three times a day); Sacral fungal infection apply until heals.” The Routine Visit (Comprehensive) date 03/20/2024, 03/22/2024, 03/26/2024, 04/02/2024, 04/10/2024, and 04/17/2024 documents: Sacrum: pressure ulcer, stage 2, Incision/Wound Tissue Observed: Epithelial, Surrounding Tissue: Intact. The Routine Visit (Comprehensive) dated 04/26/2024 documents: “;sacrum, not addressed; Type: Pressure Ulcer.” The Routine Visit (Comprehensive) by the registered nurse dated 03/20/2024, 03/22/2024, 03/26/2024, 04/02/2024, 04/10/2024, and 04/17/2024 lacks documented evidence of the assessment for fungal infection. There is no documented evidence of the update on the comprehensive or reassessment of the progress toward the response to care and the outcome by the IDG. On 05/02/2023 at 12:30pm, the Chief Medical Doctor, the Chief Operating Officer, the Director of Clinical Services, the Director of Patient Services, and Clinical Director were interviewed and did not provide an explanation for the findings.”

“Based on clinical record review and staff interview the hospice failed to ensure that care and services are provided in accordance with the established written Plan of Care. This was evident for four (4) of twenty-seven (27) clinical records reviewed (Patient # 6, #20, #23 and # 26). Failure to ensure that care and services being provided to patients are in accordance with the established written Plan of Care has the potential for negative patient outcomes. The findings are: 3. Patient #23 has a Start of Care date of 04/19/2023, discharge date 10/19/2023, with the following diagnoses: “Parkinsons Disease, Pressure Ulcer of Sacral Region Stage 3, Weight Loss, Bedbound” documented in the Physician’s Orders/Plan of Care dated 10/16/2023 to 12/14/2023. The Physician’s Orders/Plan of Care dated 10/16/2023 to 12/14/2023 documents Skilled Nursing (SN) wound orders: “;Treatment covered, wound care to (Right) achillies tendon unstageable (pressure ulcer), paint with Betadine, and leave open to air QD (every day).” The Registered Nurse Recertification Assessment note dated 10/16/2023 and 10/18/2023 document the pressure ulcer on right heel (Achillies tendon) has “;healed.” The Physician’s Orders/Plan of Care dated 10/16/2023 to 12/14/2023 lacks documented evidence of being updated and revised to reflect the patient no longer needs wound care to the right heel (achilles tendon). On 05/02/2024 at 12:20pm, the Chief Medical Director, the Associate Vice President of Hospice Clinical Services, the Clinical Director, the Chief Operating Officer, the Director of Quality Management, and the Senior Vice President of Business Development were interviewed and did not provide and explanation for the finding. 4.Patient #26 has a Start of Care date of 09/06/2023 with the diagnosis “Lung Cancer” documented in the Physician’s Orders/Plan of Care dated 03/04/2024 to 05/02/2024. The Physician’s Orders/Plan of Care dated 03/04/2024 to 05/02/2024 documents orders for Skilled Nursing: “;1-3 x week x 9 weeks (one to three visits a week for nine weeks); 2 PRN (two visits as needed) for status change;” “;Assess for response to prescribed medications;” “;Instruct in meds (medications) – use, actions, side effects to report to RN (Registered Nurse)/MD (Medical Doctor).” The Skilled Nurse Routine Visit note dated 03/15/2024 documents: patient is alert, oriented x 4, able to make needs known, has “;frequent UTIs (urinary tract infections),” and “;is incontinent of B/B (bowel/bladder).” The Clinical Note dated 03/18/2024 documents: “;T/C (Telephone call) from pts (patients) (family member);” “;pt(patient) urine is cloudy, foul smell, pt(patient) is confused. SN (Skilled Nurse) called MD (name) ordered Cipro (antibiotic) 500mg BID (two times a day) for 5 days. (Family) is instructed and voiced understanding.” The Supplemental Orders dated 03/19/2024 document: “;03/19/24 Ciprofloxacin HCL By Mouth, Tablet 500 mg, 1 Tablet b.i.d (two times a day) PO (by mouth) for 5 days ended on 03/23/24.” The clinical record lacks documented evidence of a skilled nurse visit to assess the patients change in mental and urinary status in accordance with the plan of care. The clinical record documents a routine Skilled Nurse visit was conducted four days after the family reported the patient change in status and symptoms of urinary tract infection. The Skilled Nurse Routine Visit note dated 03/22/2024 documents: patient is alert, oriented x 4, urinary symptoms – none, and “;Medication taught this visit: no medications taught.” The Skilled Nurse visit note lack documented evidence of the skilled nurse instructing the patient on the antibiotic use, actions, side effects to report, and the patients response to the antibiotic. The clinical record lacks documented evidence of the skilled nurse following the Physician’s Orders/Plan of Care. On 05/03/2024 at 1:45pm, the Associate Vice President of Hospice Clinical Services, the Clinical Director, the Chief Operating Officer, the Director of Quality Management, and the Senior Vice President of Business Development were interviewed and did not provide an explanation for the finding. 2.Patient#20 has a Start of Care date of 01/30/24 with diagnoses of “CHF (Congestive Heart Failure), Mitral Regurgitation, Tricuspid Regurgitation, Dyspnea” documented in the Physicians Plan of Care dated 01/30/24 to 04/28/24. The Physicians Plan of Care dated 01/30/24 to 04/28/24 documents: “;SN (Skilled Nurse) 1-3 x week x 13 weeks (one to three times a week for thirteen weeks), 2 PRN (as needed): Status change.” The Physicians Plan of Care dated 01/30/24 to 04/28/24 documents: “;Sacrum – Stage 1: Cleanse with NSS (Normal Saline Solution), pat dry, apply Mupirocin ointment. Cover with protective dressing. Clean OD (once daily) and PRN if soiled. Left buttocks stage 1: Cleanse with NSS (Normal Saline Solution), pat dry, apply Mupirocin ointment. Cover with protective dressing. Clean OD (once daily) and PRN if soiled. Left lower leg-skin tear: Cleanse with NSS (Normal Saline Solution), pat dry, apply xeroform and secure. Cover with protective dressing. Clean OD (once daily) and PRN if soiled.” There is no documented evidence of the individualized Physician’s Plan of Care identifying who will perform daily wound care. The Routine Visit by Registered Nurse dated 02/08/2024 documents: “;Left Buttock, Pressure Ulcer Stage1, Healed.” There is no documented evidence that patient received treatment for Left buttocks stage 1 after 02/08/2024. There is no documented evidence of supplemental order to discontinue left buttocks stage 1 treatment. The Routine Visit by Registered Nurse dated 02/12/2024 documents: “;Sacrum, Pressure Ulcer Stage1, Healed.” There is no documented evidence that patient received treatment for Sacrum stage 1 after 02/12/2024. There is no documented evidence of supplemental order to discontinue sacrum stage 1 treatment. The IDT (Interdisciplinary Team) Assessment dated 03/05/24 documents: “;New wound on right ankle, started as a skin tear, now draining purulent discharge, daily wound care with wound spray and Medi honey, Stage II on coccyx has improved, now longer purple in color, daily barrier cream.” There is no documented evidence of supplemental order for new wound (right ankle), and Stage II coccyx treatment. There is no documented evidence of the individualized Physician’s Plan of Care that identifies current wound treatment. On 05/03/2024 at 1:45pm, the Chief Medical Doctor, the Chief Operating Officer, the Directors of Clinical Services, the Director of Patient Services, and Clinical Director were interviewed and did not provide an explanation for the findings. 1.Patient #6 has a Start of Care date of 10/22/2023 with the following diagnoses “Senile Degeneration of Brain, Atherosclerotic PVD with Ulceration, Weakness” documented on the Physician’s Order/ Plan of Care for the Certification Period 01/20/2024 to 04/18/2024. The Physicians Order/Plan of Care for the Certification Period 01/20/2024 to 04/18/2024 documents the following:” Medication: Medihoney Wound/Burn Dressing External 1 (one) Application Daily EX PRN (as needed) for wound care Treatment covered: Right Lateral Leg: Right Anterior Foot: Right Ankle: Right Lateral Foot: Left Lower Leg: Left Lateral Ankle: Left Dorsal Foot: Clean with N/S (Normal Saline), pat dry, apply appropriate ointment, cover with DPD (Dry Protective Dressing), Change QD (every day)/PRN (as needed) if soiled.” The Hospice Routine SN (Skilled Nurse) visits dated 01/26/2024, 02/02/2024, 03/04/2024, 03/27/2024 documents:” RN provided wound care to the right leg Left Lower Leg: Pressure Ulcer: Stage 3 Healing: Healed Left Lateral Ankle: Pressure Ulcer: Stage 1 Healing: Healed Left Dorsal Foot: Pressure Ulcer: Stage 3 Healing: Healed” The clinical record lacks documented evidence of the skilled nurse providing wound care to the left lower leg: left lateral ankle: and the left dorsal foot. There is no documented evidence of an interim order to discontinue wound treatment. On 05/03/2023 at 2:30 pm, the Associate Vice President of Hospice Clinical Services, the Clinical Director, the Chief Operating Officer, the Director of Quality Management, and the Senior Vice President of Business Development were interviewed and did not provide an explanation for the findings.”

“Based on clinical record review, hospice policy and procedure review, and staff interviews, the hospice failed to ensure the Interdisciplinary Group (IDG) reviewed and revised the individualized Plan of Care (POC) as the patient’s care needs change, but no less frequently than every fifteen (15) days. This was evident for one (1) of twenty-seven (27) clinical records reviewed (Patient #13). Failure to ensure the IDG (Interdisciplinary Group) review, and revise the Plan of Care has the potential for negative patient outcome. The findings are: 1. Patient #13 has a Start of Care date of 11/30/2023 with the following diagnoses “Senile Degeneration of Brain, Dementia Associated with other Underlying Disease Without Behavioral Disturbance” documented in the Physicians Orders/Plan of Care dated 02/28/2024 to 05/27/2024. The Physicians Orders/Plan of Care dated 02/28/2024 to 05/27/2024 documents: “;MSS (medical social services) 1-4 x week x 12 weeks (one to four times a week for twelve weeks).” The Team Care Plan dated 04/30/2024 documents: “;MSS (medical social services) certification period beginning 02/28/2024, 1-4 x month x 3 months (one to four times a month for three months).” There is no documented evidence that the frequency of medical social services was reviewed and revised, two different orders from the plan of care and IDG meeting. On 05/03/2023 at 1:45pm, the Chief Medical Doctor, the Chief Operating Officer, the Directors of Clinical Services, the Director of Patient Services, and Clinical Director 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 services are provided in accordance with the Plan of Care. This was evident for two (2) of twenty-seven (27) clinical records reviewed (Patient: #8 and #13). Failure to ensure that services are provided in accordance with the Plan of Care has the potential for negative patient outcome. The findings are: 1. Patient #8 has a Start of Care date of 03/20/2023 with the following diagnoses “Alzheimers Dementia, Dementia Associated with Other Underlying Disease with Anxiety” documented in the Physicians Orders/Plan of Care dated 03/14/2024 to 05/12/2024. The Physicians Orders/Plan of Care dated 03/14/2024 to 05/12/2024 documents: VO (volunteer) 1-4 x month x 2 months (one to four times a month for two months). The clinical records lack documented evidence of volunteer visits. There is no documented evidence that the services are being provided in accordance with the plan of care. On 05/02/2024 at 11:30am, the Director of Clinical Services was interviewed and stated, “;the volunteer is on vacation, and have not submitted the notes.” On 05/02/2023 at 12:30pm, the Chief Medical Doctor, the Chief Operating Officer, the Directors of Clinical Services, the Director of Patient Services, and Clinical Director were interviewed and no further explanation for the findings. 2. Patient #13 has a Start of Care date of 11/30/2023 with the following diagnoses “Senile Degeneration of Brain, Dementia Associated with other Underlying Disease Without Behavioral Disturbance” documented in the Physicians Orders/Plan of Care dated 02/28/2024 to 05/27/2024. The Physicians Orders/Plan of Care dated 02/28/2024 to 05/27/2024 documents: “;SN (skilled nurse) 1-4 x week x 12 weeks (one to four times a week for twelve weeks).” The clinical records documents skilled nurse visits on 02/28/20224, 03/06/2024, 03/14/2024, 03/20/2024, 04/02/2024, 04/08/2024, 04/17/2024, and 04/24/2024. There is no documented evidence of a skilled nurse visit for the week of 03/24/2024 to 03/30/2024, missed one visit. There is no documented evidence that the services are being provided in accordance with the plan of care. On 05/03/2023 at 1:45pm, the Chief Medical Doctor, the Chief Operating Officer, the Directors of Clinical Services, the Director of Patient Services, and Clinical Director were interviewed and did not provide an explanation for the findings.”

“Based on clinical record reviews and interviews the hospice failed to ensure that all Hospice Aides received complete written patient care instructions prepared by a Registered Nurse (RN). This is evident for two (2) of twenty-seven (27) clinical records reviewed (Patient #8 and #9). Failure to ensure that all Hospice Aides receive complete written patient care instructions prepared by a Registered Nurse (RN), has the potential for negative patient outcomes. The findings are: 1.Patient #8 has a Start of Care date of 03/20/2023 with the following diagnoses “Alzheimers Dementia, Dementia Associated with Other Underlying Disease with Anxiety” documented in the Physicians Orders/Plan of Care dated 03/14/2024 to 05/12/2024. The Physicians Orders/Plan of Care dated 03/14/2024 to 05/12/2024 documents: “;Nutrition: Puree Diet.” The Charts/Clinical Notes by the Physical Therapy dated 03/15/2024 documents: “;Ambulation unable.” The Charts/Clinical Notes by the Registered Nurse dated 03/20/2024 documents: “;Pt (patient) is able to transfer with 2 persons assistance.” The HHA (home health aide) Plan of Care dated 03/28/2024 documents: Diet: Mechanical Soft; Assist with Ambulation – Indoor and Outdoor, Frequency 4 times per visit; and Transfer assist to/from bed to wheelchair – Frequency 6 times per visit. There is no documented evidence of an accurate written patient care instructions for a hospice aide – should be on puree diet, non-ambulatory, and requires 2 persons assist with transfer as per the assessment. The Routine Visit dated 03/22/2024, 03/26/2024, 04/17/2024, and 04/26/2024 documents: Physical / Musculoskeletal - Functional Status: Activity Intolerance; Mobility: Stays in Recliner Chair; Muscle Strength: Continued weakness.” The Duty Sheet documents: Assist with walking on 03/11/2024 to 03/15/2024, 3/18/2024 to 03/22/2024, 03/25/2024 to 03/29/2024, 04/01/2024 to 04/05/2024, 04/08/2024 to 04/12/2024, and 04/15/2024 to 04/19/2024. There is no documented evidence of an adequate aide supervision by the registered nurse - aides are assisting patient with walking, but non ambulatory as per the assessment. On 05/02/2023 at 12:30pm, the Chief Medical Doctor, the Chief Operating Officer, the Directors of Clinical Services, the Director of Patient Services, and Clinical Director were interviewed and did not provide an explanation for the findings. 2. Patient #9 has a Start of Care date of 12/20/2022 with the following diagnoses “Congestive Heart Failure, Weakness, Shortness of Breath” documented in the Physicians Orders/Plan of Care dated 04/13/2024 to 06/11/2024. The Physicians Orders/Plan of Care dated 04/13/2024 to 06/11/2024 documents: “;Aide 1-5 x week x 9 weeks, 1-4h duration (one to five times a week for nine weeks, one to four hours).” The HHA (home health aide) Plan of Care dated 01/04/2022 and 04/26/2024 documents: “;Assist with Ambulation – Indoor, and Transfer: assist to/from bed.” The Routine Visit dated 02/05/2024, 02/20/2024, 03/18/2024, and 04/15/2024 documents: Physical / Musculoskeletal Mobility: Bedbound.” There is no documented evidence of an accurate written patient care instructions for a hospice aide – assist with walking and transfer, should be bedbound as per assessment. The Duty Sheet documents: Assist with walking on 04/15/2024 to 04/19/2024 and 04/23/2024 to 04/26/2024. There is no documented evidence of an adequate aide supervision by the registered nurse - aides are assisting patient with walking, but non ambulatory as per the assessment. On 05/02/2023 at 12:30pm, the Chief Medical Doctor, the Chief Operating Officer, the Directors of Clinical Services, the Director of Patient Services, and Clinical Director were interviewed and did not provide an explanation for the findings.”

“Based on clinical record review and staff interview the hospice failed to ensure aide services are being provided as ordered in the aides plan of care. This was evident for six (6) of twenty-seven (27) clinical records reviewed (Patients: #1, #8, #15, #16, #20, and #21). Failure to ensure aide services are provided as ordered in the aides care plan (POC), has the potential for negative patient outcomes. The findings are: 3.Patient #15 has a Start of Care date of 01/17/2024 with diagnoses of “Late Effect of Cerebrovascular Accident, Schizophrenia, MDD (major depressive disorder)” documented in the Physicians Plan of Care dated 04/16/24 to 07/14/24. The Physicians Plan of Care dated 04/16/24 to 07/14/24 documents: “;AID (Home Health Aide) 1-5 x week x 13 weeks (one to five times a week for 13 weeks), 1-3h (hours) duration; 1-3 h(hours) duration 2PRN (as needed): acute clinical changes.” The HHA (Home Health Aide) Plan of Care dated 04/16/2024 documents: “;Turn and Position: Frequency (check mark) Every 2 hours/visit.” The Duty Sheet from 4/22/2024 to 04/26/2024 lacks documented evidence of patient being turned every 2 hours/visit. There is no documented evidence that the Home Health Aides providing services as outlined in the HHA (Home Health Aide) Plan of Care. On 05/02/2023 at 12:30pm, the Chief Medical Doctor, the Chief Operating Officer, the Director of Clinical Services, the Director of Patient Services, and Clinical Director were interviewed and did not provide an explanation for the findings. 4.Patient #16 has a Start of Care date of 12/29/23 with diagnoses of “Prostate Cancer, Metastasis to Bone, Weight Loss, Dementia, Hypertension” documented in the Physicians Plan of Care dated 12/29/23 to 03/27/24. The Physicians Plan of Care dated 12/29/23 to 03/27/24 documents: “;AID (Home Health Aide) 3-5 x week x 13 weeks (three to five times a week for 13 weeks), 3-5h (hours) duration; 1-3 h(hours) duration 2 PRN (as needed): For Status Change.” The HHA (Home Health Aide) Plan of Care dated 01/03/2024 documents: “;Turn and Position: Frequency (check mark) Every 2 hours/visit.” The Duty Sheet dated 02/12, 02/13, 02/14, 02/16, 02/19/, 02/20, and 2/21 lacks documented evidence of patient being turned every 2 hours/visit. There is no documented evidence that the Home Health Aides providing services as outlined in the HHA (Home Health Aide) Plan of Care. On 05/02/2023 at 12:30pm, the Chief Medical Doctor, the Chief Operating Officer, the Director of Clinical Services, the Director of Patient Services, and Clinical Director were interviewed and did not provide an explanation for the findings. 5. Patient #20 has a Start of Care date of 01/30/24 with diagnoses of “CHF (Congestive Heart Failure), Mitral Regurgitation, Tricuspid Regurgitation, Dyspnea” documented in the Physicians Plan of Care dated 01/30/24 to 04/28/24. The Physicians Plan of Care dated 01/30/24 to 04/28/24 documents: “;AID (Home Health Aide) 1-5 x week x 12 weeks (one to five times a week for 12 weeks), 1-3h (hours) duration; 1-3 h(hours) duration 2PRN (as needed): For Status Change.” The HHA (Home Health Aide) Plan of Care dated 02/01/2024 documents: “;Turn and Position: Frequency (check mark) Every 2 hours/visit.” The Duty Sheet dated 04/15, and 04/22 lacks documented evidence of patient being turned every 2 hours/visit. There is no documented evidence that the Home Health Aides providing services as outlined in the HHA (Home Health Aide) Plan of Care. On 05/03/2023 at 1:45pm, the Chief Medical Doctor, the Chief Operating Officer, the Directors of Clinical Services, the Director of Patient Services, and Clinical Director were interviewed and did not provide an explanation for the findings. 6.Patient #21 has a Start of Care date of 01/04/24 with diagnoses of “Hemiplegia as Late Effect of Cerebrovascular Accident, Dysphagia, Dyspnea” documented in the Physicians Plan of Care dated 03/04/24 to 05/02/24. The Physicians Plan of Care dated 03/04/24 to 05/02/24 documents: “;AID (Home Health Aide) 3-5 x week x 9 weeks (three to five times a week for 9 weeks), 1-3h (hours) duration; 30m(minutes) - 4 h(hours) duration 2PRN (as needed): as per status change.” The HHA (Home Health Aide) Plan of Care dated 03/04/2024 documents: “;Turn and Position: Frequency (check mark) Every 2 hours/visit.” The Duty Sheet dated 04/15, 04/16, 04/17, 04/18, 04/19, 04/22, 04/23, 04/24, 04/25, and 4/26 lacks documented evidence of patient being turned every 2 hours/visit. There is no documented evidence that the Home Health Aides providing services as outlined in the HHA (Home Health Aide) Plan of Care. On 05/03/2023 at 1:45pm, the Chief Medical Doctor, the Chief Operating Officer, the Directors of Clinical Services, the Director of Patient Services, and Clinical Director were interviewed and did not provide an explanation for the findings. 2. Patient #8 has a Start of Care date of 03/20/2023 with the following diagnoses “Alzheimers Dementia, Dementia Associated with Other Underlying Disease with Anxiety” documented in the Physicians Orders/Plan of Care dated 03/14/2024 to 05/12/2024. The HHA (home health aide) Plan of Care dated 03/28/2024 documents: Weight Patient and Record - frequency each visit; Temp (temperature), Pulse, and Respirations - frequency each visit. The Duty Sheet lacks documented evidence of patients weight, temperature, pulse and respiration on the following visits: 03/28/2024, 03/29/2024, 04/01/2024 to 04/05/2024, 04/09/2024 to 04/12/2024, and 04/15/2024 to 04/19/2024. There is no documented evidence that the hospice aide tasks are being provided according to the plan of care. On 05/02/2023 at 12:30pm, the Chief Medical Doctor, the Chief Operating Officer, the Directors of Clinical Services, the Director of Patient Services, and Clinical Director were interviewed and did not provide an explanation for the findings. 1.Patient #1 has a Start of Care date of 08/13/2022 with the following diagnoses “;Late Onset Alzheimer Disease, Parkinsons Disease without Dyskinesia, Weakness, Anxiety” documented on the Physician’s Order/ Plan of Care for the Certification Period 04/04/2024 to 06/02/2024. The Physician’s Order/ Plan of Care for the Certification Period 04/04/2024 to 06/02/2024 documents: “AID (Home Health Aide) 1-5 x week x 8 weeks (one to five times a week for eight weeks), 1-3h (hours) duration” The HHA (Home Health Care) Plan of Care dated 04/04/2024 documents” task: “Turn and Position” Frequency: a check mark in the box “;Every 1-2 hours/visit.” There is no documented evidence of the task “Turn and Position” services being performed by the aides on 04/08/2024 to 04/12/2024, 04/15/2024 to 04/19/2024, 04/22/2024 to 04/26/2024. There is no documented evidence of the aides providing patient care services in accordance with the HHA Plan(s) of Care (POC). On 05/03/2024 at 02:30 pm, the Associate Vice President of Hospice Clinical Services, the Clinical Director, the Chief Operating Officer, the Director of Quality Management, and the Senior Vice President of Business Development were interviewed and did not provide an explanation for the findings.”

“Based on clinical record review and staff interview the hospice failed to ensure that the supervising nurse assessed and ensured that all Hospice Aides followed the patient’s plan of care for completion of tasks assigned. This is evident for four (4) of twenty-seven (27) clinical records reviewed (Patients: #8, #9, #10, and #14). Failure to ensure that the supervising nurse assess and ensure all Hospice Aides follow the patient’s plan of care for completion of tasks assigned has the potential for negative patient outcomes. The findings are: 1. Patient #8 has a Start of Care date of 03/20/2023 with the following diagnoses “Alzheimers Dementia, Dementia Associated with Other Underlying Disease with Anxiety” documented in the Physicians Orders/Plan of Care dated 03/14/2024 to 05/12/2024. The Physicians Orders/Plan of Care dated 03/14/2024 to 05/12/2024 documents: “;Aide 1-5 x week x 9 weeks, 1-4h duration (one to five times a week for nine weeks, one to four hours).” The Aide supervision dated 03/15/2024, 03/22/2024, 03/27/2024, 04/19/2024, 04/15/2024, and 04/26/2024 lacks documented evidence of the complying with infection control policies and procedures and reporting changes in the patients condition. On 05/02/2023 at 12:30pm, the Chief Medical Doctor, the Chief Operating Officer, the Directors of Clinical Services, the Director of Patient Services, and Clinical Director were interviewed and did not provide an explanation for the findings. 2. Patient #9 has a Start of Care date of 12/20/2022 with the following diagnoses “Congestive Heart Failure, Weakness, Shortness of Breath” documented in the Physicians Orders/Plan of Care dated 04/13/2024 to 06/11/2024. The Physicians Orders/Plan of Care dated 04/13/2024 to 06/11/2024 documents: “;Aide 1-5 x week x 9 weeks, 1-4h duration (one to five times a week for nine weeks, one to four hours).” The Aide supervision dated 04/14/2024, 04/15/2024, and 04/21/2024 lacks documented evidence of the complying with infection control policies and procedures and reporting changes in the patients condition. On 05/02/2023 at 12:30pm, the Chief Medical Doctor, the Chief Operating Officer, the Directors of Clinical Services, the Director of Patient Services, and Clinical Director were interviewed and did not provide an explanation for the findings. 3. Patient #10 has a Start of Care date of 11/19/2023 with the following diagnoses “Chronic Obstructive Pulmonary Disease, Dyspnea” documented in the Physicians Orders/Plan of Care dated 02/17/2024 to 05/16/2024. The Physicians Orders/Plan of Care dated 02/17/2024 to 05/16/2024 documents: “;Aide 1-2 x week x 13 weeks, 1-8h duration (one to two times a week for thirteen weeks, one to eight hours).” The Aide supervision dated 02/20/2024 and 02/27/2024 lacks documented evidence of the complying with infection control policies and procedures and reporting changes in the patients condition. On 05/02/2023 at 12:30pm, the Chief Medical Doctor, the Chief Operating Officer, the Directors of Clinical Services, the Director of Patient Services, and Clinical Director were interviewed and did not provide an explanation for the findings. 4. Patient #14 has a Start of Care date of 12/07/2023 with the following diagnoses “Cancer of Left Breast, Visual Hallucination, Dyspnea, Osteoarthritis” documented in the Physicians Orders/Plan of Care dated 03/06/2024 to 06/03/2024. The Physicians Orders/Plan of Care dated 03/06/2024 to 06/03/2024 documents: “;Aide 1-5 x week x 13 weeks, 1-6h duration (one to five times a week for thirteen weeks, one to six hours).” The Aide supervision dated 03/06/2024, 03/13/2024, 03/20/2024, 03/25/2024, 04/10/2024, and 04/16/2024 lacks documented evidence of the complying with infection control policies and procedures and reporting changes in the patients condition. On 05/03/2023 at 1:45pm, the Chief Medical Doctor, the Chief Operating Officer, the Directors of Clinical Services, the Director of Patient Services, and Clinical Director 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 the patients clinical record include complete and updated clinical notes that reflect the patients current wound status/treatment. This was evident for one (1) of twenty-seven (27) patient care records reviewed (Patient #20). Failure to ensure clinical records include clinical notes that reflect the patients current wound status/treatment, has the potential for negative patient outcomes The findings are: 1. Patient #20 has a Start of Care date of 01/30/24 with diagnoses of “CHF (Congestive Heart Failure), Mitral Regurgitation, Tricuspid Regurgitation, Dyspnea” documented in the Physicians Plan of Care dated 01/30/24 to 04/28/24. The Physicians Plan of Care dated 01/30/24 to 04/28/24 documents: “;SN (Skilled Nurse) 1-3 x week x 13 weeks (one to three times a week for thirteen weeks), 2 PRN (as needed): Status change.” The Physicians Plan of Care dated 01/30/24 to 04/28/24 documents: “;Sacrum – Stage 1: Cleanse with NSS (Normal Saline Solution), pat dry, apply Mupirocin ointment. Cover with protective dressing. Clean OD (once daily) and PRN (as needed) if soiled. Left buttocks stage 1: Cleanse with NSS (Normal Saline Solution), pat dry, apply Mupirocin ointment. Cover with protective dressing. Clean OD (once daily) and PRN (as needed) if soiled. Left lower leg-skin tear: Cleanse with NSS (Normal Saline Solution), pat dry, apply xeroform and secure. Cover with protective dressing. Clean OD (once daily) and PRN (as needed) if soiled.” The IDT (Interdisciplinary Team) Assessment dated 02/21/24 documents: “;Skin, dusky and dehydrated with stage II on coccyx.” The Routine Visit by Registered Nurse dated 02/22/2024 documents: “;Sacrum, Pressure Ulcer, Stage I, Healed.” The Registered Nurse Assessment dated 02/22/2024 lacks documented evidence of change in wound stage. The IDT (Interdisciplinary Team) Assessment dated 03/05/24 documents: “;New wound on right ankle, started as a skin tear, now draining purulent discharge, daily wound care with wound spray and Medi honey, Stage II on coccyx has improved, now longer purple in color, daily barrier cream.” The Routine Visit by Registered Nurse dated 03/07/2024 documents: “;Sacrum, Pressure Ulcer, Stage I, Healed.” The Registered Nurse Assessment dated 03/07/2024 lacks documented evidence of an accurate wound assessment/treatment. The IDT (Interdisciplinary Team) Assessment dated 04/16/24 documents: “;Skin with multiple bruising on both shins, coccyx with erythema, no open areas but new red spot on coccyx, use of daily barrier cream.” The Routine Visit by Registered Nurse dated 04/18/2024 documents: “;Sacrum, Pressure Ulcer, Stage I, Healed.” The Registered Nurse Assessment dated 04/18/2024 lacks documented evidence of an accurate wound assessment/treatment. The clinical record lacks documented evidence of accurate registered nurse clinical notes that reflects patients current wound status/treatment. On 05/03/2023 at 1:45pm, the Chief Medical Doctor, the Chief Operating Officer, the Directors of Clinical Services, the Director of Patient Services, and Clinical Director were interviewed and did not provide an explanation for the findings.”