Good Shepherd Hospice

“Based on patient record review and staff interview, the Hospice did not ensure the prompt delivery of medications/Comfort pack provided by the Hospice as needed to meet the patient’s needs. This was evident in one (1) of three (3) records reviewed (Patient #1). Failure to ensure that the medications/Comfort pack were promptly delivered has the potential for negative patient outcomes. 1) Patient #1 has a referral and encounter note dated 05/14/2026, the Registered Nurse documents that the patient and partner/primary caregiver are agreeable to Hospice. Discussed Hospice services and Hospice levels of care as per Medicare guidelines. Medication review will be done by Hospice Nurse upon admission. Tentative discharge date of 05/14/2026 from the hospital.The clinical record lacks documented evidence of Hospice admission on 05/14/2026 as scheduled. The telephone encounter notes of 05/14/2026 documents that the primary caregiver was informed that a nurse is not available for 05/16/2026, a nurse would be sent on 05/18/2026. The primary caregiver agrees. The “On-Call” log dated 05/17/2026 at 07: 25PM documents that the patient/partner/caregiver called reporting that the patient had a “seizure”. The patient is scheduled for admission on Monday 05/18/2026. Primary caregiver states they need someone now and it is agreeable for a 12:30 AM admission visit on 05/18/2026. Discussed possible Inpatient Unit admission and hospitalization with primary caregiver who declined. The Plan of Care for certification period 05/18/26 to 08/08/26 document orders for “Skilled Nurse 1 visit every day for one day, 1 - 4 (one to four) visits every week for 12 (twelve weeks), 1 - 5 (one to five) visits as needed”. Hospice diagnoses including “Secondary Malignant Neoplasm of Liver, Malignant Neoplasm of Female Breast, Hepatic Cirrhosis, and Ascites”. The Hospice Benefit Election is dated 05/18/2026. The clinical record documents Registered Nurse visits conducted on 05/18/2026:05/18/26 at 01:00 AM – abbreviated Nursing admission. The Registered Nurse documents the patient’s “pain level of 4/10 (4 out of 10 pain scale), after pain medications, frequent and relieving factors Hydromorphone”. The Care Plan problem list indicates the patient was assessed for pain and family educated on analgesic regimen. The clinical note lacks documented evidence of the name, dosage, and route of the medication that the family was educated on. The medication profile dated 05/18/2026 generated by the Registered Nurse documents the patient’s medications include Haldol 1 milligram sublingual every 4 hours as needed for - agitation, Atropine sulfate 1 milligram sublingual every 4 hours as needed for – secretions, dyspnea, Tylenol 650 milligram per rectal every 6 hours as needed for – mild pain and elevated temperature, Lorazepam/Ativan 1 milligram oral every 8 hours as needed for – anxiety/sleep, Compazine 10 milligram oral every 6 hours as needed for – nausea/vomiting. The medication profile does not include Hydromorphone. The encounter notes dated 05/18/2026 at 12:30PM documents telephone call made to primary caregiver and family regarding Codeine allergy. The continued Nursing admission assessment visit dated 05/18/2026 at 12:45 PM – 02:15 PM, the Registered Nurse documents the patient’s pain as 0/10 (0 out of 10 pain scale), no pain. Caregivers have been administering Xanax 0.5 milligrams/Dilaudid 2 milligrams crushed in slurpy as per MD’s instructions. They are awaiting delivery of Comfort kit. The Care Plan problem list indicates the patient was assessed for pain and family educated on analgesic regimen. The clinical note lacks documented evidence of the name, dosage, and route of the medication that the family was educated on. There is no documented evidence that the Hospice ensures that the Comfort pack medications were promptly delivered to the patient on 05/18/2026 prior to time of death. Immediate pain management medications were given as per order of the patient’s private/primary Medical Doctor. The Hospice did not ensure that the Hospice pain management medications/Comfort pack was delivered to the patient promptly in a timely manner to ensure the effective pain management of the Hospice patient. The survey findings were reviewed on 06/15/2026 at 01:44 PM with the Director of Patient Services and Performance Improvement Director.”

“Based on record reviews and staff interviews, the Hospice failed to ensure a comprehensive assessment is conducted to identify all patient’s needs to provide the appropriate treatments and services, this was evident for -- (-) of twenty-seven (27) clinical records reviewed. (Patients #8). Failure to ensure assessments are comprehensive has the potential for unmet patient needs. 1) Patient #8 has start of care date 10/31/2024 with diagnoses of Acute respiratory failure, spastic quadriplegic cerebral palsy, intellectual disability, and S/P percutaneous endoscopic gastrostomy (PEG) tube placement as documented on “;The Hospice Plan of Care” for certification period 10/31/2024 to 1/28/2025. The Hospice Plan of Care for certification period 10/31/2024 to 1/28/2025 documented orders for Skilled Nurse (SN) visits 1 to 2 visits every week for 13 weeks; Problem: Hospice Diet and Nutrition – Jevity 1.5 infusing @ 50ml/hour (hr.) via PEG tube with Kangaroo pump with 55ml water flush every 1 hr. for 20 hrs. Staff to manage. The initial Skilled Nurse Hospice visit notes dated 10/31/2024 lacked documented evidence related to the scrotal edema. 1. Skilled Nurse Hospice visit notes dated 11/3/2024, 11/04/2024, 11/12/2024, 11/20/2024, 11/25/2024, 12/10/2024, and 12/17/2025 lacked documented evidence related to the scrotal edema. Skilled Nurse Hospice visit notes documented the following: 12/28/2024 – “;Pt (patient) has small skin irritation around his scrotum, scrotum swollen, barrier cream to apply daily reviewed with facility staff.” No documented evidence the Medical Doctor was notified regarding edema. 01/07/2025 – “;Scrotal swelling persists which is patient baseline per staff.” No documented evidence the Medical Doctor was notified regarding edema. Hospice Plan of Care IDG (Interdisciplinary Group) dated 12/27/2024 documented, “;Scrotal swelling persists which is pt (patient) baseline as per staff.” 1. Skilled Nurse Hospice visit notes dated 11/03/2024, 11/04/2024, 11/26/2024 lacked documented evidence related to the assessment of PEG tube insertion site. Skilled Nurse Hospice visit notes reviewed from 11/03/2024 to 01/07/2025 lacked consistent documentation regarding assessment of the PEG tube insertion site. Skilled Nurse Hospice visit notes documented the following: 11/12/2024 – G-tube insertion site with no redness. 11/20/2024 – G-tube feeds as ordered. Skin warm, dry and intact. 12/04/2024 – G-tube site clean and dry split gauze in place. 12/10/2024 – G-tube site with no signs and symptoms of infection. 12/17/2024 – G-tube site with no signs and symptoms of infection. 12/28/2024 – Feed tube in place site intact. 01/07/2025 - G-tube site with no signs and symptoms of infection. On 1/10/2025 the Director of Patient Services was interviewed and stated a head-to-toe assessment should be completed on admission and the PEG tube insertion site and scrotal edema should be assessed at each visit and documented in the nurses note. No further information was provided.”

“Based on review of clinical records and interviews, the hospice failed to develop an individualized Plan of Care that that reflects all patients pertinent diagnoses, services, and treatments. This was evident in three (3) of twenty -seven (27) clinical records (Patient #1, # 12 and # 18). Failure to provide services in accordance with the Plan of Care has the potential for unmet patient needs and negative patient outcomes. 2) Patient #1 has a start of care date of 03/15/24 with diagnosis of Alzheimer’s Dementia, Transplant wound granuloma, and Malignant Neoplasm of prostate as documented on the “Hospice Plan of Care” for certification period 11/10/2024 to 01/08/2025. The “Hospice Plan of Care” for certification period 11/10/2024 to 01/08/2025 documents orders for “Skilled Nurse 1 to 2 visits every week for 9 weeks. Wound location: mid lower abdomen. Skilled clinician as needed: remove old dressing and discard as per policy, cleanse with wound cleanser, dry with sponge or gauze pad, apply to wound bed Mupirocin 2%, cover with (cdd) clean dry dressing, change dressing daily- caregiver independent, measure wound length, depth, width weekly”. The “Skilled Nurse Hospice visit” notes dated 11/14/24, 11/22/24, 11/27/24, 11/29/24, 12/6/24, 12/11/24, 12/20/24, 12/26/24, and 1/2/25 lack documented evidence that the Skilled Nurse performed wound measurement. A Home Visit was conducted with the Skilled Nurse on 01/07/2025 with the Skilled Nurse. The Skilled was observed performing wound care measurement to the mid-lower abdominal area. There was no observable cleansing of the wound with wound cleanser as ordered in the Plan of Care. The Hospice “Wound Assessment” policy dated 09-2024 documents “Reassessment and documentation of wound should include 1) wound measurement weekly, 2) wound bed description, 3) clinical evaluation of wound progress”. The Hospice did not ensure that Skilled Nurse services and wound care treatments are provided in accordance with the individualized Plan of Care and Hospice policy. Survey findings and Interview were conducted on 01/07/2025 at 03:30 PM with the Administration staff, Director of Performance Improvement, and Director of Patient Services. No explanation was provided. 3) Patient #12 has a start of care date of 07 04/2024 with diagnoses of “Alzheimer’s Dementia, and Urinary Incontinence” as documented on the “;Hospice Plan of Care” for certification period 10/02/2024 to 12/30/2024. The “Hospice Plan of Care” for certification period 10/02/2024 to 12/30/2024 documents an order for “Medical Social Work 1 to 2 visits every month for three months, 6 as needed visits for social support and crisis” The Medical Social Work visits are dated 10/29/2024 and 12/16/2024. The clinical record lacks documented evidence of a Medical Social Work visit conducted during the month of 11/2024 to ensure the continued need for social support of the Hospice recipient and primary caregivers. The survey findings and interview were conducted on 01/09/2024 at 04:10 PM with the Administration staff, Director of Performance Improvement, and Director of Patient Services. No explanation was provided. 1) Patient # 18 has a start of care date of 10/02 2024 with diagnoses of Lewy Body Dementia, Parkinsons, Type 2 Diabetes, Hyperlipidemia, Prostate Cancer as documented on the “Hospice Plan of Care” for certification period of 01/01/2025 to 03/30/2025. The “Hospice Plan of Care” for certification period of 01/01/2025 to 03/30/2025 documents orders for: “Skilled Nurse visits 1 to 3 visits every week for fourteen weeks, 1 to 6 visits as needed for symptoms management. Medical Social Worker 1 to 2 visits every month for four months and 1 to 6 visits as needed for psychosocial crisis.” The Hospice Plan of Care Interdisciplinary Group (IDG) dated 10/02/2024 documented the following Problem: “Risk for skin breakdown related to immobility. Goal: Patient verbalizes understanding of infection prevention strategies and methods to prevent development or worsening of pressure injuries. Caregiver will verbalize understanding of infection prevention strategies and methods to prevent development or worsening of pressure injuries. Intervention: Prevention of Pressure Injuries: Instruct caregiver in the causes and prevention of pressure injuries including positioning strategies and using pressure relieving devices/strategies. Instruct in dietary/nutritional needs to optimize skin health and healing.” Master of Social Work (MSW) Hospice Visit note dated 10/29/2024 documents: “;SW (social worker) spoke to Licensed Practical Nurse (LPN) who states Pt (patient) has a wound on his buttocks that they are treating.” The note lacked documented evidence the hospice RN was notified regarding wound. Skilled Nurse Hospice Visit note dated 10/31/2024 lacked documented evidence related to wound. Skilled Nurse Hospice Visit note dated 11/04/2024 documents: “Integumentary: Pressure Injury developed to sacrum (0.5 cm x 0.5 cm) Stage II. Encounter Notes: Charge Nurse present and reports patient has developed pressure injury to sacrum (small) otherwise no new concerns. The Wound Assessment: Sacrum Medial Stage 2. Measurements: 0.5 cm x 0.5 cm x 0.1 cm. Treatment: Wound Cleanser water and soap and treatment/intervention barrier cream.” The Skilled Nurse Hospice Visit note dated 11/04/2024 lacked documented evidence that the Risk for Skin Breakdown problem area had been updated to reflect the patients current stage 2 pressure ulcer. The Hospice “Wound Assessment” policy dated 09-2024 documents “Reassessment and documentation of wound should include 1) wound measurement weekly, 2) wound bed description, 3) clinical evaluation of wound progress.” The record lacked documented evidence the wound was re-assessed weekly after 11/04/2024 per the agencies Wound Assessment Policy dated 09/2024. The Skilled Nurse Hospice Visit notes dated 11/07/2024, 12/02/2024, and 12/05/2024 lacked documented evidence related to wound. The Skilled Nurse Hospice Visit note dated 11/21/2024 documents: “;Facility staff reports skin intact.” The Skilled Nurse Hospice Visit note dated 12/11/2024 documented, “;Wound to sacrum improving and educated facility staff on off-loading patient to prevent skin injury. Wound Assessment: Sacrum Medial Stage 2. Measurements: 0.5 cm x 0.5 cm x 0.1 cm. Treatment: Wound Cleanser water and soap and treatment/intervention barrier cream.” The Wound Assessment dated 12/18/2024 documented the pressure injury was removed (discontinued 12/18/2024) due to “;wound healed.” Survey findings and interviews were conducted on 1/13/2024 at 10:16 am and 1:34 pm with the Director of Patient Services. An email provided to the surveyor documented her interview with MSW, “;The MSW stated her usual practice was to notify the RN or Team Manager of findings. Does not recall if this occurred.” Interview with the RN related to visit on 10/31/2024, “;patient was seen at the nurses station and didnt mention any changes with skin, due to the patients history of agitation she left the patient in his current area to not disrupt him too much.” No additional information or explanation was provided.”

“Based on clinical record review and staff interview, the Hospice failed to develop an individualized Plan of Care that that reflects all patients pertinent diagnoses, Skill Nursing interventions and dietary requirements for three (3) of twenty-seven (27) records reviewed (Patients #4, #6 and #8). Failure to provide services in accordance with the Plan of Care has the potential for unmet patient needs and negative patient outcomes. 2) Patient # 4 has a start of care date of 11/22/2024 with one diagnosis of “Alzheimer’s Dementia” as documented on the “Hospice Plan of Care” for certification period 11/22/2024 to 02/19/2025. The “Hospice Plan of Care” for certification period 11/22/2024 to 02/19/2025 documents orders for “Skilled Nurse 1 to 2 visits every week for 14 weeks. Skilled Nurse intervention - Drain site care, cleanse with alcohol, apply drain sponge, gauze dressing and cover transparent dressing weekly and as needed. Drain method - self suctioning. Instruct caregiver to empty cholecystostomy drain bulb when half full and record output. Flush drain with 5 milliliter Normal Saline daily. Primary care giver independent”. The initial and comprehensive assessment dated 11/22/2024, the Skilled Nurse/Registered Nurse documents patient has right upper quadrant “Cholecystostomy drain to be flush drain with 5 milliliter Normal Saline daily. Primary care giver independent”. The Hospice Plan of Care lacks documented evidence of pertinent diagnoses related to the Cholecystostomy tube and Dietary/Nutritional requirement. The survey findings and interview were conducted on 01/09/2025 at 04:00 PM with the Administration staff, Director of Performance Improvement, and Director of Patient Services. No explanation was provided. 3) Patient #6 has a start of care date of 05/07/2024 with diagnoses of “Severe Alzheimer’s Dementia, Hypernatremia, Acute Renal Failure, Hypermagnesemia, and Dysphagia” as documented on the “Hospice Plan of Care” for certification period 01/02/2025 to 03/02/2025. The “Hospice Plan of Care” for certification period 01/02/2025 to 03/02/2025 documents orders for “Skilled Nurse 1 to 2 visits every week for 10 weeks. Medications include: Starch Thickening Liquid 1000 milliliters add thick it liquid to food and drinks as directed. Tick-It starch -malt Dextrin 1020 gram take one scoop by mouth as needed for nectar thick liquids, follow packaging instructions. Route -oral, indications - difficulty swallowing”. The Plan of Care lacks an order for modified Dietary restrictions and Skilled Nurse interventions to address the patient’s dietary restrictions. The survey findings and interview were conducted on 01/09/2025 at 04:18 PM with the Administration staff, Director of Performance Improvement, and Director of Patient Services. No explanation was provided. 1) Patient #8 has start of care date 10/31/2024 with diagnoses of acute respiratory failure, spastic quadriplegic cerebral palsy, intellectual disability, and S/P percutaneous endoscopic gastrostomy (PEG) tube placement as per the “Hospice Plan of Care” for certification period 10/31/2024 to 1/28/2025. The “Hospice Plan of Care” for certification period 10/31/2024 to 1/28/2025 documented orders for “Skilled Nurse (SN) visits 1 to 2 visits every week for 13 weeks; Problem: Hospice Diet and Nutrition: Jevity 1.5 infusing @ 50ml/hour (hr.) via PEG tube with Kangaroo pump with 55ml water flush every 1 hr. for 20 hrs. Staff to manage.” Skilled Nurse Hospice visit notes dated 10/31/2024, 11/03/2024, 11/04/2024, 11/26/2024 lacked documented evidence related to the assessment of PEG tube insertion site. The Hospice Plan of Care lacked documented evidence related to the skin assessment of the PEG tube insertion site. On 1/10/2025 the Director of Patient Services was interviewed and stated a head-to-toe assessment should be completed on admission and the PEG tube insertion site should be assessed at each visit and documented in the nurses note. No further information was provided.”

“Based on clinical record review and staff interview, the Hospice failed to ensure pain and symptom management is accurately reflected in the clinical record. This was evident in one (1) of twenty-seven (27) clinical records reviewed. (Patient #11). Failure to ensure the effective pain and symptom management, has the potential for negative patient outcome. Patient #11 has a start of care date of 11/22/2024 with diagnoses of Malignant Neoplasm of Right Female Breast, Secondary Malignant Neoplasm of Bone, Neoplasm related pain, Pathological Fracture of Rib of Left side as documented on the “Hospice Plan of Care” for certification period 11/22/2024 to 02/20/2025. The “Hospice Plan of Care” for certification period 11/22/2024 to 02/20/2025 documents orders for “Skilled Nurse 1 to 2 visits every week for 13 weeks. Skilled Nurse intervention - assess pain each visit. The “Skilled Nurse Hospice visit” note dated 11/27/2024 documents inconsistent pain level. The “Pain Assessment” section documents “no pain”. The “Edmonton symptom assessment system” documents the patient’s pain level of “8” (on scale of 0 - 10). The “Encounter note” lacks documentation of pain intervention. There is no documented evidence of intervention to address the patient’s high pain level of 8. The “Skilled Nurse Hospice visit” note dated 12/10/2024 documents inconsistent pain level. The “Pain Assessment” section documents pain level “8/10” (on scale of 0 - 10). The “Edmonton symptom assessment system” documents the patient’s pain level of “1”. ). The “Encounter notes”, the Skilled Nurse documents “reports pain has very much improved after increase of Fentanyl patch to 100 microgram every 3 days, 2 days ago”. There is no documented evident of interventions to address the patient’s current high pain level of 8. The “;Skilled Nurse Hospice visit” note dated 12/23/24, documents inconsistent pain level. The “Pain Assessment” section documents patient’s pain level of “5/10” (on scale of 0 - 10). The “Encounter notes”, the Skilled Nurse documents the patient reports “verbal pain 8/10”. Patient stated she should be taking pain medication now. Medication reconciliation completed with new order for Morphine 20 milligram per oral”. Patient stated it has been effective with conflicting pain level”. The clinical record lacks documentation of accurate pain assessment, intervention and resolution to the patient’s pain level. The survey findings and interview were conducted on 01/09/2025 at 03:45 PM with the Administration staff, Director of Performance Improvement, and Director of Patient Services. No explanation was provided.”

“Based on clinical record review and interview, the Hospice failed to ensure communication and an ongoing sharing of information with the interdisciplinary Group. This was evident in one (1) of twenty-seven (27) records reviewed (Patient #18). Failure to ensure effective communication with the Interdisciplinary Group has the potential for the unmet patient needs and negative patient outcomes. Patient # 18 has a start of care date of 10/02/2024 with diagnoses of Lewy Body Dementia, Parkinsons, Type 2 Diabetes, Hyperlipidemia, Prostate Cancer as documented on the Hospice Plan of Care for certification period of 01/01/2025 to 03/30/2025. The Hospice Plan of Care for certification period of 01/01/2025 to 03/30/2025 documents orders for “Skilled Nurse visits 1 to 3 visits every week for fourteen weeks, 1 to 6 visits as needed for symptoms management. Medical Social worker 1 to 2 visits every month for four months and 1 to 6 visits as needed for psychosocial crisis.” The Hospice “Wound Assessment” policy dated 09-2024 documents “Reassessment and documentation of wound should include 1) wound measurement weekly, 2) wound bed description, 3) clinical evaluation of wound progress.” The Hospice Plan of Care Interdisciplinary Group (IDG) dated 10/02/2004 documented the following: “Problem: Risk for skin breakdown related to immobility. Goal: Patient verbalizes understanding of infection prevention strategies and methods to prevent development or worsening of pressure injuries. Caregiver will verbalize understanding of infection prevention strategies and methods to prevent development or worsening of pressure injuries. Intervention: Prevention of Pressure Injuries: Instruct caregiver in the causes and prevention of pressure injuries including positioning strategies and using pressure relieving devices/strategies. Instruct in dietary/nutritional needs to optimize skin health and healing.” The Master of Social Work (MSW) Hospice Visit note dated 10/29/2024 documented, “;SW (social worker) spoke to Licensed Practical Nurse (LPN) who states Pt (patient) has a wound on his buttocks that they are treating.” The Skilled Nurse Hospice Visit note dated 10/31/2024 lacked documented evidence related to wound. The IDG notes dated 10/02/2024, 10/04/2024, and 10/11/2024 documented skin intact. The IDG note dated 10/25/2024 lacked documented evidence related to skin assessment. Survey findings and interviews were conducted on 1/13/2024 at 10:16 am and 1:34 pm with the Director of Patient Services. An email provided to the surveyor documented her interview with MSW, “;The MSW stated her usual practice was to notify the RN or Team Manager of findings. Does not recall if this occurred.” Interview with the RN related to visit on 10/31/2024, “;patient was seen at the nurses station and didnt mention any changes with skin, due to the patients history of agitation she left the patient in his current area to not disrupt him too much.” No additional information or explanation was provided.”

“Based on clinical record review and staff interview, the Hospice failed to provide nursing care and services by or under the supervision of a registered nurse. This is evident in one (1) of the twenty-seven (27) clinical records reviewed. (Patient #10) Failure to provide nursing care services under the supervision of a registered nurse has the potential for negative patient outcomes. The findings are: Patient #10 has a start of care date 06/07/2024 with diagnoses that include Alzheimer’s, dementia and depression documented on the “Hospice Plan of Care” for the certification period 12/04/2024-02/01/2025. The “Hospice Plan of Care” for the certification period 12/04/2024-02/01/2025 documents orders for “Skilled Nurse one (1) to two (2) visits every week for nine (9) weeks. Five (5) visits are needed. Comments: symptom management” The “Encounter Notes” dated 01/07/2025 documents a Licensed Practical Nurse (LPN) visit. “2:00pm LPN (Licensed Practical Nurse) visit at The Bristal in Bethpage. Received pt (patient) sitting in common area in wheel chair. Pt (patient) alert with confusion. Unable to make needs known. RSP even on R/A (room air). ABD (abdomen) soft and non-tender. +BS (bowel sounds). No S/S (signs/symptoms) pain or discomfort. Supplies ordered. Called pt (patient) daughter to update on visit with no answer. Message left. ALF (assisted living facility) made aware to call GSH (Good Shepherd Hospice) with any questions or concerns.” There is no documented evidence the Licensed Practical Nurse reported their assessment to a Registered Nurse. The survey findings and interview were conducted on 01/09/2025 at 3:30pm with the Director of Performance Improvement, Director of Patient Services and Administration staff. No explanation was provided.”

“Based on home visit observation, clinical record review and staff interview, the Hospice failed ensure dietary counselling and intervention necessary are provided to patients as condition progresses. This was evident in the one (1) of six (6) home visits conducted (Patient # 3). Failure to ensure patients nutritional changes are assessed by a qualified individual can result in negative patient outcomes. Patient #3 has a start of care date of 12/26/2024 with diagnoses of late onset Alzheimer’s Dementia, Hypertension, Stroke , and Transient Ischemic Attack as documented on the “Hospice Plan of Care” for certification period of 02/26/2024 to 02/23/2025. The “Hospice Plan of Care” for certification period of 12/26/2024 to 02/23/2025 documents order for Skilled Nursing, 1 to 2 visits every week for 10 weeks; 1 to 6 visits as needed for 10 weeks for pain and symptoms management. The skilled nursing plan of care note dated 12/27/2024 documented patient had a 12 lb. weight loss with recent vomiting when trying to eat. A home visit was conducted on 01/07/2025 at the Skilled Nursing Facility where patient resides. Patient’s family member was present and informed surveyors patient has problem swallowing, tends to pocket food and appetite has declined. The record lacked documented evidence that the Hospice referred the patient for swallowing and dietary evaluation. Survey findings and interview were conducted on 01/07/2025 at 2:15.PM with the Hospice Nurse and Supervisor. No explanation was provided. The survey findings were reviewed with Hospice Administrator, and Director of Patient Services at the exit conference on 01/13/2025.”

“Based on home visit observation, clinical record review and staff interview, the Hospice failed to ensure coordination and evaluation of services between the Hospice and the skilled nursing facility. This was evident in the one (1) of six (6) home visits conducted (Patient #3). Failure to ensure coordination of services has the potential for negative patient outcomes. Patient #3 has a start of care date of 12/26/2024 with diagnoses of late onset Alzheimer’s Dementia, Hypertension, Stroke, and Transient Ischemic Attack as documented on the “Hospice Plan of Care” for certification period of 12/26/2024 to 02/23/2025. The “Hospice Plan of Care” for certification period of 12/26/2024 to 02/23/2025 documents order for “Skilled Nursing, 1 to 2 visits every week for 10 weeks; 1 to 6 visits as needed for 10 weeks for pain and symptoms management”. The clinical record lacked documented evidence of communication between the IDG (Interdisciplinary Group) and the skilled nursing facility. A home visit was conducted on 01/07/2025 between 2:00PM and 2:45PM at the Skilled Nursing Facility where patient resides. The Skilled Nursing Facility staff were interviewed during the visit. The staff at the facility denied having received training in Hospice Care Philosophy, the Hospice’s Policy and Procedure, and written instructions for hospice-related interventions. Survey findings and interview were conducted on 01/07/2025 at 3:55.PM with the Hospice Nurse and Supervisor. No explanation was provided. The survey findings were reviewed with Hospice Administrator, and Director of Patient Services at the exit conference on 01/13/2025.”

“Based on clinical record review and staff interview, the Agency failed to ensure the Interdisciplinary Group coordinate and communicate pertinent changes in patient conditions at all Interdisciplinary Group meetings. This was evident in one (1) of three (3) clinical records reviewed. Patient #1. Failure to ensure that the Interdisciplinary Group coordinate and communicate pertinent changes in patient conditions, has the potential for negative patient outcome. The findings include: Patient #1 has a start of care date of 07/20/2023 with diagnoses of Diffuse large B-Cell Lymphoma, Secondary Malignant Neoplasm of Retro perineum and Peritoneum, Malignant Ascites, Encounter for change or removal of drains, and Pleural Effusion as documented on the “;Physicians Order and Plan of Care” dated 07/20/2023 – 10/17/2023. The “;Physicians Order and Plan of Care” dated 07/20/2023 – 10/17/2023 and 10/18/2023 to 01/17/2024 documents: Skilled Nurse 1x day x1 one visits a week for one week), 6 PRN (six visits as needed), 1x day x2 (one visit a week for two weeks), 1 -2 x week x 12 weeks (one to two visits a week for twelve weeks). A” Supplemental Order” dated 07/20/23 documents: Oxygen 2 – 4 liters per minute intermittent via Nasal Cannula”. The Skilled Nurse visit note dated 08/02/2023, the Licensed Practical Nurse documents the “;patient “;daughter c/o (complaint of) that patient had a cough. No cough noted during visit and patient denies cough”. The visit record note dated 08/06/2023, the Skilled Nurse documents the patents “;left eyes appears blood shot due to possible persistent coughing. TC (telephone call) to Medical Doctor and Diflucan 100 mg (milligram) ordered for six (6) days and Tussin DM Q 6-hour PRN (every six hours as needed). The visit record note dated 08/07/203, the Registered Nurse documents “;Oxygen at 3 Liters/minute. Respiration labored upon exertion. Crackles noted on auscultation. The visit record note dated 08/09/2023, the Licensed Practical Nurse documents “;cough has decreased”. The visit record note dated 08/14/2023, the Registered Nurse documents “;cough better, stopped Tussin. Respiration even and unlabored”. The Interdisciplinary Team meeting dated 08/17/2023 lacks documentation of the patients cough and pertinent medication changes for respiratory symptom management. The visit record note dated 08/21/2023, the Registered Nurse documents “;Respiration even and unlabored on Oxygen at 3 Liters per minute via Nasal Cannula. Breath Sounds diminished bilaterally”. The visit record note dated 08/28/2023 and 09/05/2023, the Registered Nurse documents “;Respiration even and unlabored on Oxygen 3 Liters per minute via Nasal Cannula. Breath sounds decreased on right side”. The Interdisciplinary Team meeting dated 08/31/2023 lacks documentation of the changes in the patients condition and diminished breath sounds. The Interdisciplinary Group did not maintain coordination, communication, discussion, and documentation of changes in patient conditions at all Interdisciplinary Group meetings. The survey findings and interview were conducted on 12/11/2023 at 2:50 PM with the Director of Patient Services and President of Quality Improvement. No explation was provided.”