Homecare & Hospice

“Based on review of clinical records and interviews with staff, the hospice failed to ensure for three (3) of three (3) clinical records (Patients #1, 2, and 3) the order for Morphine Sulfate is incomplete and lacks specific orders for administration based on the patient’s symptoms. In addition, Patient #3 has an incomplete Ativan order which lacks specific orders for administration based on the patient’s symptoms. Further, for Patients #1, 2, and 3, the clinical record lacks clear documentation regarding dosages administered, the effectiveness of drug therapy, side effects, and patient compliance and interactions. Failure to complete an accurate and comprehensive drug review has the potential for patients to receive unintended dosages of medication, ineffective symptom management and prevents the Interdisciplinary Team (IDT) from effectively assessing the effectiveness and safety of the drug therapy, which has the likelihood for patient harm. Findings:The agency failed to ensure comprehensive drug reviews are completed as evidenced by the following: Patient #1 – This 69-year-old patient with a terminal diagnosis of end stage heart failure was admitted to the hospice on 01/09/2026. Review of the Physician’s orders/Plan of Care for certification period 01/09/2026 to unknown end date revealed an order for morphine sulfate by mouth solution 20mg/ml: 5-20mg every 2 hours as needed for pain or shortness of breath. The order is incomplete and lacks specific instructions for administration of varying dosages based on the severity of the patient’s symptoms (pain and/or shortness of breath). It is unclear how the patient determines the dosage for administration as the order is for a range of 5 mg (0.5 ml) to 20 mg (1ml) of morphine. Review of the Admission Skilled Nurse Visit dated 01/09/2026 revealed the Registered Nurse documented that the patient was initiated on an as needed opioid (pain medication) and was provided with education regarding the dose and frequency of the medication. There is no documentation that specifies whether that patient was educated about how to determine the quantity of morphine to be administered (morphine ordered in range of 5 mg (0.5 ml) to 20 mg (1ml)), how the patient/caregiver should track and report medication administration, dosages, side effects and the effectiveness of the medication so that the hospice could effectively monitor the effectiveness of the drug therapy. Review of the Skilled Nursing clinical note dated 01/16/2026 revealed the patient is taking 1ml (20 mg) of morphine every 2 to 3 hours for pain The clinical note lacks specificity regarding documentation of a drug review to include: the amount of medication administered (dosage), side effects or interactions with other medications to determine the effectiveness of the drug therapy and compliance with the medication order, which states that the frequency of administration is every 2 hours as needed. Review of the IDT (Interdisciplinary Team) Meeting Record dated 01/21/2026 revealed documentation that the patient is taking “ 0.5ml (20 mg) of morphine every 2 to 3 hours.” The information reported to the IDT is inconsistent with the Skilled Nurse clinical notes. Additionally, there is no documented discussion regarding the amount of medication the patient receives (actual dosages) within a specified timeframe, side effects or interactions to determine the effectiveness of the drug therapy and compliance with the medication order, which states that the frequency of administration is every 2 hours as needed. The hospice failed to ensure that comprehensive drug reviews are completed. During interview on 02/20/2026 at 4:40 PM, the Registered Nurse responsible for case management of this patient stated they were unsure as to why there are discrepancies in the amount of morphine being utilized by the patient and may have been a miscommunication between the care team. During further interview on 02/20/2026 at 03:17 PM the RN Supervisor responsible for oversight of clinical care stated the Registered Nurse should have discussed medication and symptom management during IDT meetings and confirms it is not documented in the meeting record. The RN supervisor confirmed that the agency’s expectation is for nurses to complete a medication reconciliation at each visit. During this time the nurses are to confirm dosage and frequency of use of pain management medications, determine any medication changes since last visit, and assess supply of medications in the home. The RN supervisor further stated they will need to re-educate nurses on completion and documentation of medication reconciliation. Patient #2 – This 78-year-old patient with a terminal diagnosis of heart failure was admitted to the hospice on 01/16/2026. A. Review of the Physician’s Orders/Plan of Care for certification period 01/16/2026 to unknown end date revealed an order for morphine sulfate by mouth solution 20mg/ml: 0.25 to 1ml every two hours as needed for pain, dyspnea, or restlessness. The order is incomplete and lacks specific instructions for administration based on the severity of the patient’s symptoms (pain and/or shortness of breath). It is It is unclear how the patient determines the dosage for administration as the order is for a range of 5 mg (0.5 ml) to 20 mg (1ml) of morphine. Review of the admission skilled nurse visit dated 01/16/2026 revealed the Registered Nurse documented that the patient was initiated on an as needed opioid (pain medication) and was provided with education regarding the dose and frequency of the medication. There is no documentation that specifies whether that patient was educated about when the patient should administer 2.5 mg (0.25 ml) or 20 mg (1ml) of the ordered morphine or how the patient/caregiver should track and report medication administration, dosages, side effects and the effectiveness of the medication so that the hospice could effectively monitor the effectiveness of the drug therapy. Review of the Skilled Nursing Clinical note dated 01/16/2026 revealed the Registered Nurse documented that the patient reports 8/10 pain (0 being no pain and 10 being the worst pain) since fall at hospital and is having difficulty moving. The RN administered 1ml of morphine to the patient. The clinical note lacks specificity regarding documentation of a drug review to include: a review of the overall medication usage ) (frequency and specific doses being utilized as varies throughout the record), side effects or interactions with other medications to determine the effectiveness of the drug therapy. Review of the Skilled Nursing Clinical note dated 01/20/2026 revealed the Registered Nurse documented the patient is more alert is receiving 0.25-0.5ml of morphine roughly 3 to 4 times daily. The clinical note lacks specificity regarding documentation of a drug review to include: the amount of medication administered (dosage), side effects or interactions with other medications to determine the effectiveness of the drug therapy and compliance with the medication order, which states that the frequency of administration is every 2 hours as needed. Review of the IDT meeting record dated 02/03/2026 reveals the Registered Nurse reported the following: patient’s pain is currently 0/10 (0being no pain and 10 being the worst pain). Education provided on pain such as premedicating prior to incontinence care with 0.25ml (medication unspecified). Family reports they are giving a “half dose of 0.5ml,” which the RN educates on being more than 0.25ml and possibly contributing to patient’s lethargy. The information related to medication usage, dosage and reported pain shared with the IDT is inconsistent with the Skilled Nurse clinical notes. Additionally, there is no documented discussion regarding the amount of medication the patient receives (actual dosages) within a specified timeframe, side effects or interactions to determine the effectiveness of the drug therapy and compliance with the medication orders. During interview on 02/20/2026 at 3:03 PM, the RN Supervisor stated that the ranges are given on comfort pack medications so the nurses can adjust dosages to achieve pain control as symptoms worsen without having to obtain new orders for each titration. The current dosage should be reflected in clinical assessments and IDT notes but is not always done. The RN Supervisor further stated that they were unaware that either parameter for use or a supplemental order with specific dosing is required within the plan of care. During further interview on 02/20/2026 at 03:17 PM the RN Supervisor stated the Registered Nurse should have discussed medication and symptom management during IDT meetings and confirms it is not documented in the meeting record. The RN supervisor confirmed that the agency’s expectation is for nurses to complete a medication reconciliation at each visit. During this time the nurses are to confirm dosage and frequency of use of pain management medications, determine any medication changes since last visit, and assess supply of medications in the home. The RN supervisor further stated they will need to re-educate nurses on completion and documentation of medication reconciliation. B. Review of the clinical record reveals an order for the following: Ativan 0.5mg tablet 1-2 tabs every 4 hours as needed for restlessness, agitation, insomnia, and alcohol dependency. Review of the Skilled Nursing Clinical Note dated 01/16/2026 revealed the Registered Nurse documented the following: Physician said to give Ativan every 4 hours as patient has a history of heavy alcohol intake and now currently not drinking. The clinical note lacks documentation regarding the exact amount of medication the patient is receiving, side effects or interactions with other medications to determine the effectiveness of the drug therapy. Review of the Skilled Nursing Clinical note dated 02/10/2026 revealed the Registered Nurse documented the Caregiver reports the patient is yelling out and throwing items. Discussion is had regarding administering giving Ativan on a 4 hour scheduled to help with confusion and aggression. The clinical note lacks documentation regarding the exact amount of medication the patient is receiving, side effects or interactions with other medications to determine the effectiveness of the drug therapy. Review of the IDT meeting records dated 01/20/2026 and 02/03/2026 lack documented evidence that symptom management related to Ativan (including dosage and usage) were reviewed. During interview on 02/20/2026 at 3:03 PM, the RN Supervisor stated that the ranges are given on comfort pack medications so the nurses can adjust dosages to achieve symptom control as symptoms worsen without having to obtain new orders for each titration. The current dosage should be reflected in clinical assessments and IDT notes but is not always done. The RN Supervisor further stated that they were unaware that either parameter for use or a supplemental order with specific dosing is required within the plan of care. During further interview on 02/20/2026 at 03:17 PM the RN Supervisor stated the Registered Nurse should have discussed medication and symptom management during IDT meetings and confirms it is not documented in the meeting record. The RN supervisor confirmed that the agency’s expectation is for nurses to complete a medication reconciliation at each visit. During this time the nurses are to confirm dosage and frequency of use of pain management medications, determine any medication changes since last visit, and assess supply of medications in the home. The RN supervisor further stated they will need to re-educate nurses on completion and documentation of medication reconciliation. Patient #3 – This 86-year-old patient with a terminal diagnosis of malignant neoplasm (cancerous tumor) of the lung was admitted to the hospice on 12/22/2025. Review of the Physician’s orders/Plan of Care for certification period 012/22/2025 to unknown end date revealed an order for morphine sulfate by mouth tablet 7.5mg tablet every 4 hours as needed, morphine sulfate by mouth solution 20mg/ml: 5-20mg every 2 hours as needed, and hydrocodone-acetaminophen tablet 5-325mg 1 tab every 6 hours as needed. The orders are incomplete, lacking a qualifier for when to use each as needed medication. The orders also lack specific instructions for determining which pain medication to administer based on the severity of the patient’s symptoms. It is unclear when the patient should utilize morphine tablets vs morphine solution vs hydrocodone tablets. Review of the Admission Skilled Nurse Visit dated 12/22/2025 revealed the Registered Nurse documented that the patient was initiated on an as needed opioid (pain medication) and was provided with education regarding the dose and frequency of the medication. There is no documentation that specifies whether the patient was educated about when the patient should administer 5 mg (0.5 ml) or 20 mg (1ml) of the ordered morphine, utilize morphine tablets vs morphine solution, vs hydrocodone tablets, or how the patient/caregiver should track and report medication administration, dosages, side effects and the effectiveness of the medication so that the hospice could effectively monitor the effectiveness of the drug therapy. Review of the Skilled Nursing Hospice Visit dated 01/05/2026 revealed the Registered Nurse documented the following: Medications taught – norco (hydrocodone-acetaminophen) – give pain medication in between the scheduled by mouth morphine. The clinical note lacks specificity regarding documentation of a drug review to include: the amount of medication administered (dosage), side effects or interactions with other medications to determine the effectiveness of the drug therapy and compliance with the medication order, as well as reviewing and updating the as needed morphine order to reflect a scheduled frequency versus as needed. The plan of care lacks documented evidence that an order for scheduled morphine tablets was ever obtained. Review of the IDT (Interdisciplinary Team) Meeting Record dated 01/09/2026 revealed the Registered Nurse documented the patient’s pain is a 3/10 (0 being no pain and 10 being the worst pain) with pain reported in the abdomen and back. The information reported to the IDT is inconsistent with the Skilled Nurse clinical notes. Additionally, there is no documented discussion regarding the amount of medication the patient receives (actual dosages) within a specified timeframe, side effects or interactions to determine the effectiveness of the drug therapy and compliance with the medication orders. Review of the Skilled Nursing Hospice Visit dated 01/19/2026 revealed the Registered Nurse documented the following: “Patient is no longer taking oxycodone as norco (hydrocodone-acetaminophen) is more effective.” The clinical note lacks specificity regarding documentation of a drug review to include: the amount of medication administered (dosage), side effects or interactions with other medications to determine the effectiveness of the drug therapy and compliance with the medication order. Additionally, it is unclear as to whether the patient was prescribed oxycodone. The medication orders signed by the physician lack evidence of the patient being prescribed oxycodone from start of care until time of survey. Review of the IDT (Interdisciplinary Team) Meeting Record dated 01/21/2026 and 01/28/2026 revealed the Registered Nurse documented the following: patient’s pain is a 0/10 (0 being no pain and 10 being the worst pain). The patient’s pain is well managed with taking “1 norco (hydrocodone-acetaminophen) in morning, as needed dose mid-day if needed, and ½ tablet of morphine at bedtime.” The information reported to the IDT is inconsistent with the Skilled Nurse clinical notes and physician orders. The clinical record lacks any documented evidence to support the patient was utilizing the pain medication regime reported at IDT. Review of the Skilled Nursing Clinica note dated 02/10/2026 revealed the Registered Nurse documented the following: Caregiver reports pain at this time, morphine given at HS (bedtime). The clinical note lacks specificity regarding documentation of a drug review to include: the amount of medication administered (dosage), side effects or interactions with other medications to determine the effectiveness of the drug therapy and compliance with the medication order. Review of the Skilled Nursing Hospice Visit dated 02/11/2026 revealed the Registered Nurse documented that the patient was initiated on an as needed liquid morphine for breakthrough pain and was provided with education regarding the dose and frequency of the medication. There is no documentation that specifies whether that patient was educated about when the patient should administer 2.5 mg (0.25 ml) or 20 mg (1ml) of the ordered morphine or how the patient/caregiver should track and report medication administration, dosages, side effects and the effectiveness of the medication so that the hospice could effectively monitor the effectiveness of the drug therapy. Review of the IDT (Interdisciplinary Team) Meeting Record dated 02/11/2026 revealed the Registered Nurse documented the following: patient’s pain is a 1/10 (0 being no pain and 10 being the worst pain) with some abdominal pain. The Registered Nurse reports patient had a “rough weekend with pain” and educated the caregiver on use of liquid morphine and to call. The information reported to the IDT is inconsistent with the Skilled Nurse clinical notes. Additionally, there is no documented discussion regarding the amount of medication each medication the patient receives (actual dosages) within a specified timeframe, side effects or interactions to determine the effectiveness of the drug therapy, compliance with the medication orders, or when to utilize each specific pain medication. Review of the Skilled Nursing Clinical note dated 02/13/2026 revealed the Licensed Practical Nurse documented the following: patient states he continues to take norco (hydrocodone-acetaminophen) every 6 hours and morphine tablets as needed for pain and his pain has been controlled. The clinical note lacks documentation regarding the exact amount of medication the patient is receiving, side effects or interactions with other medications to determine the effectiveness of the drug therapy. Further, the record lacks evidence that hydrocodone-acetaminophen was ordered at a frequency of every 6 hours. The hospice failed to ensure that accurate comprehensive drug reviews are completed. During interview on 02/20/2026 at 2:26 PM, the RN Supervisor stated they cannot speak to the specific drug regimen ordered for this specific patient (the Registered Nurse responsible for case management is unavailable for interview), but confirmed there should not be inconsistencies between the medication orders, clinical notes, and IDT records. During interview on 02/20/2026 at 3:03 PM, the RN Supervisor stated that the ranges are given on comfort pack medications so the nurses can adjust dosages to achieve pain control as symptoms worsen without having to obtain new orders for each titration. The current dosage should be reflected in clinical assessments and IDT notes but is not always done. The RN Supervisor further stated that they were unaware an updated order with specific dosing is required within the plan of care. During further interview on 02/20/2026 at 03:17 PM the RN Supervisor stated the Registered Nurse should have discussed medication and symptom management during IDT meetings and confirms it is not documented in the meeting record. The RN supervisor confirmed that the agency’s expectation is for nurses to complete a medication reconciliation at each visit. During this time the nurses are to confirm dosage and frequency of use of pain management medications, determine any medication changes since last visit, and assess supply of medications in the home. The RN supervisor further stated they will need to re-educate nurses on completion and documentation of medication reconciliation.”

“Based on clinical record reviews and staff interviews, three (3) of three (3) patient records (Patient #s 1, 2, and 3) lacked evidence that the hospice nurses and Interdisciplinary Team (IDT) members are performing complete 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 IDT. Issues are:- The hospice nurse failed to conduct a comprehensive assessment of the patient’s pain.- The comprehensive assessment findings are inconsistent with the information reported to the IDT by the Registered Nurse as it relates pain and use of pain medication. Failure to ensure that comprehensive assessments are updated and reflect changes in the status of the patient has the potential for the patient’s health status to be compromised and can result in the provision of poor quality of care. Patient #1 – This 69-year-old patient with a terminal diagnosis of end stage heart failure was admitted to the hospice on 01/09/2026. A. Review of the Licensed Practical Nurse Specialist clinical note dated 01/12/2026 revealed the Licensed Practical Nurse documented the patient is reporting 3/10 pain (0 being no pain and 10 being the worst pain) in their legs and feet. The LPN educated patient on the SFV (Symptom Follow-up Visit) and that the RN would be out in two days to reassess their pain. The patient declined the RN visit stating the LPN can follow up at their next visit. Review of the Skilled Nursing clinical note dated 01/14/2026 revealed the Registered Nurse documented the patient is reporting their pain is still constant in bilateral lower extremities. The RN contacted doctor’s office for long-acting pain medication. The documentation lacks a comprehensive pain assessment to include the location of the pain, character, severity, frequency, precipitators of pain, what relieves the pain, whether pain medication is being utilized (dose, frequency of use and effectiveness). It is unclear what information was provided to the patient’s physician to prompt a request for a long-acting pain medication. During interview on 02/20/2026 at 3:40 PM, the RN Supervisor stated that the LPN made a visit on 1/12/2026 and addressed the pain with the patient. The RN Supervisor further stated that the LPN is unable to complete a comprehensive assessment and the RN Should have assessed the pain being reported by the patient. B. Review of the Licensed Practical Nurse Specialist clinical note dated 01/15/2026 revealed the Licensed Practical Nurse documented the patient is still experiencing a lot of pain in legs and educated the patient on having the RN complete a symptom follow-up visit. Review of the Skilled Nursing clinical note dated 01/16/2026 revealed the Registered Nurse documented a telephone call made to the patient in an attempt to schedule a symptom follow-up visit, and the patient declines the visit and requests a refill of their morphine. The documentation lacks a comprehensive pain assessment to include the location of the pain, character, severity, frequency, precipitators of pain, what relieves the pain, whether pain medication is being utilized (dose, frequency of use and effectiveness) to include the long-acting pain medication. Additionally, there is no documentation regarding the amount of pain medication the patient has available. It is unclear what information was provided to the patient’s physician to prompt a request for a refill of pain medication. During interview on 02/20/2026 at 3:40 PM, the RN Supervisor stated that the LPN made visit on 01/15/2026 and addressed pain with the patient. The RN Supervisor further stated that the LPN is unable to complete a comprehensive assessment and the RN Should have assessed the pain being reported by the patient. C. Review of the Skilled Nursing clinical note dated 01/16/2026 revealed the Registered Nurse documented the following: “telephone call placed to patient to make a SFV and patient declined a visit just needs a refill of morphine called in. RN writer contacted primary care physician’s office to request a refill of morphine, RN got on the phone reporting that NP (nurse practitioner) will not refill the morphine because patient should have enough for 10 days. RN writer let primary care RN know that patient is taking 1 ml every 2 hours like ordered and only received 30 ml. RN writer reminded the primary care RN that the orders signed for comfort care are 5-20 mg every 2 hours for pain. RN explained that patient is still in pain 10/10 after 1.5-2 hours of morphine.” There is no documentation regarding the amount of pain medication the patient has available, and the usage of morphine reported to the physician’s office is inconsistent with the clinical notes. Review of the Clinical notes dated 01/12/2026, 01/14/2026, 01/16/2026 revealed the patient is refusing visits from the Registered Nurse to assess the patient’s pain. Review of the IDT Meeting Record dated 1/21/2026 revealed the RN documented that the patient’s pain scale ranges from 3-7 out of 10 (0 being no pain and 10 being the worst pain). Patient’s pain is back and forth in bilateral lower extremities and back. Pain regimen includes 50 mcg fentanyl patch and morphine every 2 to 3 hours. The information documented in the IDT record is inconsistent with the information in the clinical notes. Specifically, there is discrepancies in the amount and frequency of morphine being utilized. During interview on 02/20/2026 at 4:40 PM, the Registered Nurse (case coordinator for patient’s care) stated they were unsure as to why there are discrepancies between the IDT meeting record and the clinical notes. The Registered Nurse further stated that the patient continued to report pain throughout services, but that the Registered Nurse was not able to complete a comprehensive pain assessment due to refusals. Patient #2 – This 78-year-old patient with a terminal diagnosis of heart failure was admitted to the hospice on 01/16/2026. Review of the Physician’s orders/Plan of Care for certification period 01/16/2026 to unknown end date revealed an order for morphine sulfate by mouth solution 20mg/ml: 2.5mg-20mg every 2 hours as needed for pain or shortness of breath. The order is incomplete and lacks specific instructions for administration of varying dosages based on the severity of the patient’s symptoms (pain and/or shortness of breath). It is unclear when how the patient determines the dosage for administration as the order is for a range of 2.5 mg (0.25 ml) to 20 mg (1ml) of morphine. Review of the admission skilled nurse visit dated 01/16/2026 revealed the Registered Nurse documented that the patient was initiated on an as needed opioid (pain medication) and was provided with education regarding the dose and frequency of the medication. There is no documentation that specifies whether that patient was educated about how to determine the quantity of morphine to be administered (order for range of 2.5 mg (0.25 ml) to 20 mg (1ml)), how the patient/caregiver should track and report medication administration, dosages, side effects and the effectiveness of the medication so that the hospice could effectively monitor the effectiveness of the drug therapy. Review of the Skilled Nursing Clinical note dated 01/16/2026 revealed the Registered Nurse documented the patient is reporting 8/10 (0 being no pain and 10 being the worst pain) pain since fall in hospital and is having difficulty moving. The RN administered given “1ml of morphine” to the patient. The clinical note lacks specificity regarding documentation of a drug review to include: a review of the overall medication usage (frequency and specific doses being utilized as varies throughout the record), side effects or interactions with other medications to determine the effectiveness of the drug therapy. Review of the Skilled Nursing Clinical note dated 01/20/2026 revealed the Registered Nurse documented the patient is more alert is receiving 0.25-0.5ml of morphine roughly 3 to 4 times daily. The clinical note lacks specificity regarding documentation of a drug review to include: the amount of medication administered (dosage), side effects or interactions with other medications to determine the effectiveness of the drug therapy and compliance with the medication order, which states that the frequency of administration is every 2 hours as needed. Review of the IDT meeting record dated 01/20/2026 reveals the patient is experiencing 8/10 pain (0 being no pain and 10 being the worst pain) when legs or catheter are touched. Pain decreased to 6/10 (0 being no pain and 10 being the worst pain) after morphine (unspecified amount). The information reported to the IDT is inconsistent with the Skilled Nurse clinical notes. Specifically, there is discrepancies in the pain being reported and the amount and frequency of morphine being utilized. Review of the IDT meeting record dated 02/03/2026 reveals the following: the patient is experiencing 0/10 pain (0 being no pain and 10 being the worst pain). Education provided on premedicating with 0.25ml (unspecified medication) prior to incontinent care. Family reports they are giving a “half dose of 0.5ml,” which the RN educates on being more than 0.25ml and possibly contributing to patient’s lethargy. The information reported to the IDT is inconsistent with the Skilled Nurse clinical notes. Specifically, there is discrepancies in the pain being reported and the amount and frequency of morphine being utilized. During interview on 02/20/2026 at 3:03 PM, the RN Supervisor stated that all pain assessments, symptoms, and medications should be reviewed and discussed with the Medical Director at IDT meetings so that symptom management can be evaluated and adjusted as needed. The RN Supervisor further stated they are unsure why the information presented at IDT does not accurately reflect the patient’s status as documented in the clinical notes. Patient #3 – This 86-year-old patient with a terminal diagnosis of malignant neoplasm (cancerous tumor) of the lung was admitted to the hospice on 12/22/2025. Review of the Physician’s orders/Plan of Care for certification period 12/22/2025 to unknown end date revealed an order for morphine sulfate by mouth tablet 7.5mg tablet every 4 hours as needed, morphine sulfate by mouth solution 20mg/ml: 5-20mg every 2 hours as needed, and hydrocodone-acetaminophen tablet 5-325mg 1 tab every 6 hours as needed. Review of the Skilled Nursing Hospice Visit dated 01/05/2026 revealed the Registered Nurse documented the following: Medications taught – norco (hydrocodone-acetaminophen) – give pain medication in between the scheduled by mouth morphine. Review of the Admission Skilled Nurse Visit dated 01/09/2026 revealed the Registered Nurse documented that the patient was initiated on an as needed opioid (pain medication) and was provided with education regarding the dose and frequency of the medication. Review of the IDT (Interdisciplinary Team) Meeting Record dated 01/09/2026 revealed the Registered Nurse documented the patient’s pain is a 3/10 (0 being no pain and 10 being the worst pain) with pain reported in the abdomen and back. The information reported to the IDT is inconsistent with the Skilled Nurse clinical notes. Specifically, there is discrepancies in the pain being reported and the amount and frequency of morphine being utilized. Review of the Skilled Nursing Hospice Visit dated 01/19/2026 revealed the Registered Nurse documented the following: “Patient is no longer taking oxycodone as norco (hydrocodone-acetaminophen) is more effective.” it is unclear as to whether the patient was prescribed oxycodone. The medication orders signed by the physician lack evidence of the patient being prescribed oxycodone from start of care until time of survey. Review of the IDT (Interdisciplinary Team) Meeting Record dated 01/21/2026 and 01/28/2026 revealed the Registered Nurse documented the following: Pain scale: 0. Pt denies any complaints of pain. Patient is well managed with taking 1 norco (hydrocodone-acetaminophen) in morning, as needed dose mid-day if needed, and ½ tablet of morphine at bedtime. The information reported to the IDT is inconsistent with the Skilled Nurse clinical notes and physician orders. Specifically, there are discrepancies between notes related to the usage (dose and frequency) of morphine and hydrocodone. Review of the Skilled Nursing Clinica note dated 02/10/2026 revealed the Registered Nurse documented the following: Caregiver reports pain at this time, morphine given at HS (bedtime). Review of the Skilled Nursing Hospice Visit dated 02/11/2026 revealed the Registered Nurse documented that the patient was initiated on an as needed liquid morphine for breakthrough pain and was provided with education regarding the dose and frequency of the medication. Review of the IDT (Interdisciplinary Team) Meeting Record dated 02/11/2026 revealed the Registered Nurse documented the following: patient’s pain is a 1/10 (0 being no pain and 10 being the worst pain) with some abdominal pain. The Registered Nurse reports patient had a “rough weekend with pain” and educated the caregiver on use of liquid morphine and to call. The information reported to the IDT is inconsistent with the Skilled Nurse clinical notes. Specifically, there are discrepancies between notes related to the usage (dose and frequency) of morphine and hydrocodone. Review of the Skilled Nursing Clinical note dated 02/13/2026 revealed the Licensed Practical Nurse documented the following: patient states he continues to take norco (hydrocodone-acetaminophen) every 6 hours and morphine tablets as needed for pain and his pain has been controlled. During interview on 02/20/2026 at 02:22 PM, the RN Supervisor stated that all pain assessments, symptoms, and medications should be reviewed and discussed with the Medical Director at IDT meetings so that symptom management can be evaluated and adjusted as needed. The RN Supervisor further stated they are unsure why the information presented at IDT does not accurately reflect the patient’s status as documented in the clinical notes.”

“Based on clinical record review and staff interview, for one (1) out of three (3) clinical records (Patient #1), the Hospice failed to ensure that interventions for the management of pain and symptoms were re-evaluated based on changes in the patient’s status. Failure to ensure current interventions are assessed to determine their effectiveness in addressing the patient’s needs for pain and symptom management has the potential to result in unmet patient needs, may diminish quality of life for the patient and result in negative patient outcomes.Findings: Patient #1 – This 69-year-old patient with a terminal diagnosis of end stage heart failure was admitted to the hospice on 01/09/2026. Review of the Licensed Practical Nurse Specialist clinical note dated 01/12/2026 revealed the Licensed Practical Nurse documented the following: Patient said she did have pain in her legs and feet at a level of 3 out of 10 (pain scale with 0 being no pain and 10 being the most severe pain), they educated the patient on the SFV (Symptom Follow-up Visit) and told her a nurse comes out 2 days after this visit to follow up about pain and she declined SFV and said “you can just follow up with my pain when you come back on Thursday to change bandages.” Review of the Licensed Practical Nurse Specialist clinical note dated 01/14/2026 revealed the Licensed Practical Nurse documented that the patient was hunched over in their recliner, noticeably in pain, and was unable to transfer to the bed due to pain in their legs. The LPN administered 0.25ml of morphine and assisted patient back to bed. Due to the pain the patient was experiencing, they refused wound care to bilateral lower extremities. Review of the Skilled Nursing clinical note dated 01/14/2026 revealed the Registered Nurse documented the following: RN reached out to family to see how patient was feeling and if her pain was subsiding with morphine. Patient reports pain is still constant in bilateral lower extremities due to swelling… RN contacted doctor’s office for long-acting pain medication. Review of the Licensed Practical Nurse Specialist clinical note dated 01/15/2026 revealed the Licensed Practical Nurse documented the following: Legs are still in a lot of pain, and I educated patient on SFV – she said yes to one and asked if it could be a RN to assess her more. Fentanyl patch 50mcg placed on patient yesterday… educated patient and patient caregiver that patient was due for morphine and offered to give patients some but they said not right now Review of the Skilled Nursing clinical note dated 01/16/2026 revealed the Registered Nurse documented the following: telephone call placed to patient to make a SFV and patient declined a visit just needs a refill of morphine called in. RN writer contacted primary care physician’s office to request a refill of morphine, RN got on the phone reporting that NP (nurse practitioner) will not refill the morphine because patient should have enough for 10 days. RN writer let primary care RN know that patient is taking 1 ml every 2 hours like ordered and only received 30 ml. RN writer reminded primary care RN that the orders signed for comfort care are 5-20 mg every 2 hours for pain. RN explained that patient is still in pain 10/10 after 1.5-2 hours of morphine. Review of the Clinical notes dated 01/12/2026, 01/14/2026, and 01/16/2026, revealed the patient is refusing visits from the Registered Nurse to assess the patient’s pain. Review of the IDT Meeting Record dated 1/21/2026 revealed the RN documented that the patient’s pain scale ranges from 3-7 out of 10 (0 being no pain and 10 being the worst pain). Patient’s pain is back and forth in bilateral lower extremities and back. Pain regimen includes 50 mcg fentanyl patch and morphine every 2 to 3 hours. The information documented in the IDT record is inconsistent with the information in the clinical notes. Specifically, there is discrepancies between the amount and frequency of morphine being utilized by the patient as well as the severity of the pain being reported. Review of the Clinical notes dated 01/22/2026 and 01/23/2026 revealed the patient is refusing visits from the Registered Nurse to assess the patient’s pain. Review of the Licensed Practical Nurse Specialist clinical note dated 01/22/2026 revealed the Licensed Practical Nurse documented the following: Patient said she had some pain 5/10 (0 being no pain and 10 being the worst pain) in their legs, patient declined symptom follow up visit, said they do not have much pain when nothing is touching their legs. The nurse educated on taking the morphine every two hours and the patient said “no that’s what’s making me so constipated and I won’t take it anymore.” Review of the Skilled Nursing clinical note dated 01/23/2026 revealed the Registered Nurse documented the following: Patient expressing frustration with the pain in the legs. RN re-educated on morphine and elevating the legs. Patient states they do not want to take more morphine because it makes them constipated. Patient offered a symptom follow up visit for tomorrow or Sunday, patient declined stating they will take the morphine more often as needed. RN contacted Hospice Medical Director who recommends increasing fentanyl to 100mcg. Review of the Licensed Practical Nurse Specialist clinical note dated 01/26/2026 revealed the Licensed Practical Nurse documented the following: they asked the patient how they were doing and they stated their legs hurt. When asked if they were taking the morphine every 2 hours they said the same thing they said at the visit on Thursday 1/22/2026 “no that’s what’s making me so constipated and I won’t take it anymore. The nurse educated on the Senna for constipation and to take it as needed and patient said “nothing works for me.” The clinical record lacks documented evidence of completion of comprehensive pain assessments (to include the location of the pain, character, severity, frequency, precipitators of pain, what relieves the pain, whether pain medication is being utilized along with the dose, frequency of use and effectiveness) when pain is reported by the patient. Further, the clinical record lacks documented evidence that the patient’s current pain management regime was being reassessed as indicated (patient ongoing reports of pain and refusals to utilize current pain regimen due to constipation concerns) to determine the need for additional interventions to manage the patient’s pain and update the plan of care to meet the patient’s current needs. During interview on 2/20/2026 at 03:41PM, the RN Supervisor stated that agency expectation is for patients to be educated at the time of admission and ongoing on the election and conditions of participation of the hospice benefit including skilled nurse visits. Patients are educated on the requirement of skilled nursing visits to achieve symptom control and assess the overall needs of the patient. The RN supervisor further stated that with the changes in patient’s condition (uncontrolled pain), the Registered Nurse should have re-educated the patient on refusals of skilled nurse visits, conducted visits to assess patient’s uncontrolled pain and evaluate interventions, and collaborated with the IDT in order to adjust plan of care as indicated.”

“Based on review of clinical records and interviews with staff, for one (1) of three (3) clinical records (Patient #1 ), the hospice failed to ensure ongoing sharing of information between all disciplines providing care. Failure to ensure the ongoing sharing of information has the potential for unmet patient needs. Review of the agency’s policy “Interdisciplinary team, care planning, and coordination of services” dated 06/26/1991 revealed that the interdisciplinary team (IDT) will be composed of a Registered Nurse, Physician, Social Worker, and a qualified Counselor. The Registered Nurse is responsible for coordination of the IDT along with ensuring there is continuous assessment of the patient to ensure the plan of care meets all patient’s needs. The IDT is to ensure coordination of services and communication between disciplines to ensure that all care and services are delivered for the purpose of pain relief, symptom control, emotional and spiritual support, and quality of life, rather than curative treatment. This will be achieved through ensuring documentation of communication at the time of a change in the patient’s status and sharing information between all disciplines providing care and services, in all settings, whether provided directly or under arrangement. The IDT will keep attendance records as well as document the following in the clinical record: all IDT decisions, plan of care changes, updated goals, modified visit frequencies, and changes in services. Patient #1 – This 69-year-old patient with a terminal diagnosis of end stage heart failure was admitted to the hospice on 01/09/2026. A. Review of the Licensed Practical Nurse Specialist clinical note dated 01/12/2026 revealed the Licensed Practical Nurse documented the following: Patient reported pain in legs and feet rating 3/10 (0 being no pain and 10 being the worst pain), LPN educated patient on upcoming SFV (Symptom Follow-up Visit) in 2 days. The patient declined SFV stating “you (LPN) can just follow up with my pain when you come back on Thursday to change bandages.” Review of the Skilled Nursing clinical note dated 01/14/2026 revealed the Registered Nurse documented a phone call to patient to follow up on pain and the effectiveness of the morphine. Patient reports constant pain in bilateral lower extremities due to swelling. The RN contacted doctor’s office for long-acting pain medication. Review of the Skilled Nursing clinical note dated 01/16/2026 revealed the Registered Nurse documented the RN placed a phone call in attempt to schedule a SFV, however, the patient declined a visit just needs a refill of morphine called in. The RN contacted primary care physician’s office to request a refill of morphine and informed that that Nurse Practitioner would not refill the morphine because patient should have enough for 10 days. RN notified primary care office that patient is “taking 1 ml every 2 hours like ordered and only received 30ml” and that the signed orders signed for comfort care are “5-20mg every 2 hours for pain.” RN explained that patient is still in pain 10/10 (0 being no pain and 10 being the worst pain) after “1.5-2 hours of morphine”. Review of the IDT Meeting Record dated 1/21/2026 revealed the RN documented that the patient’s pain scale ranges from 3-7. Patient’s pain is back and forth in bilateral lower extremities and back. Pain regimen includes 50mcg fentanyl patch and morphine every 2 to 3 hours. The clinical record lacks documented evidence that the Registered Nurse communicated the inadequate pain management to the IDT. Further, the clinical record lacks documented evidence that the Registered Nurse updated the IDT of the ongoing refusals of symptom follow up visits made by the patient. During interview on 02/20/2026 at 4:40 PM, the Registered Nurse stated that they believe medication usage and pain were discussed in IDT meetings along with the refusal of symptom follow up visits but is unsure as it is not documented anywhere. B. Review of the Skilled Nursing clinical note dated 01/13/2026 revealed the Registered Nurse documented the following: RN reached out to family to see how patient was feeling and if pain was subsiding with morphine. Patient reports pain is still constant in bilateral lower extremities due to swelling. RN contacted primary care physician’s office for long acting pain medication. Message left with LPN. RN writer received a call back from LPN at PCP’s (primary care physician) office who stated Nurse Practitioner called in 12.5mcg fentanyl patch for patient. RN called and profiled medication with pharmacy. Family made aware of new medication. Review of the License Practical Nurse Specialist note dated 1/14/2026 revealed the LPN (License Practical Nurse) called several local pharmacies to fill 12.5mcg fentanyl patches ordered by primary care specialist the day prior but had difficulty finding a pharmacy with the dosage ordered in stock. Review of an additional License Practical Nurse Specialist note dated 1/14/2026 revealed the LPN called the PCP office and requested the fentanyl patches be sent to specific pharmacy for patient caregiver to pick up the following day. (late entry states LPN was informed by RN that an order was received for 50mcg fentanyl patches and sent to pharmacy to be picked up by patient caregiver). Review of the Registered Note dated 1/14/2026 revealed the RN contacted the Hospice Medical Director for recommendations for patient’s leg and pain control and received an order for 50mcg fentanyl patches which the caregiver would pick up that evening. It is unclear why the RN contacted the Hospice Medical Director for pain recommendations after already receiving orders for 12.5mcg from the patient’s primary care physician one day prior. Review of an additional License Practical Nurse Specialist note dated 1/15/2026 revealed the LPN received a phone call from the Pharmacist stating the patient caregiver called requesting the 12.5mcg fentanyl patches ordered by Primary Care Physician. The LPN updated the Pharmacist and apologized stating that writer was just informed that the Hospice Medical Director called 50mcg fentanyl patches into another pharmacy and the patient caregiver had already picked them up. The LPN directed Pharmacist to cancel order for 12.5mcg patches. The Pharmacist voiced concern related to special ordering the patches and the order being cancelled. The clinical record lacks documentation regarding the circumstances leading to the simultaneous ordering of two separate fentanyl patches orders with two different dosages written by two separate physicians and sent to two separate pharmacies. Further there are inconsistencies in the documentation of the communication between the Registered Nurse and Licensed Practical Nurse surrounding the ordering of the fentanyl patches. The hospice failed to ensure ongoing sharing of information between all disciplines providing care. Specifically, the Registered Nurse failed to ensure timely communication regarding updates to medication orders with other disciplines involved in the patient’s care. During interview on 02/20/2026 at 04:21 PM, the Registered Nurse stated that there were miscommunications between themselves and the Licensed Practical Nurse regarding the fentanyl patches. The Registered Nurse further stated but cannot find any documentation of why the Medical Director was consulted when the Primary Care Physician was actively managing the patient but thinks it may have had something to do with the Primary Care Physician refusing to order medications.”

“Based on review of clinical records, Public Health Laws Section 2980, 2983 and 2994-C, and interviews with staff for four (4) of sixteen (16) patients (Patient #: 3, 8, 10, and 11) without a Health Care Proxy or court approved guardian and with limited or questionable capacity to make medical decisions, the hospice failed to ensure the attending physician and a concurring physician documented an initial determination of the patients decision-making capacity to include an assessment of the cause and extent of the patients incapacity and the likelihood that the patient will regain decision-making capacity. Failure to ensure the determination of the patients decision- making capacity to make health care decisions is complete and follows the requirements in Law, has the potential to prevent patients from executing their rights. Patient #3- This 76-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified part of the right bronchus or lung was admitted to the hospice on 01/09/2024. Review of the Initial Visit dated 01/09/2024 revealed the Registered nurse documented that the patients orientation could not be assessed because the patient was minimally responsive. There is no documentation that the patient lacked capacity to make healthcare decisions and there is no evidence of a legally appointed representative. Additionally, there is no documented evidence advance directives were in place at the time of admission, and there is no documented evidence that a physician or concurring physician determined that the patient lacks decision making capacity. Review of the Charts/ Clinical Notes dated 01/09/2024 revealed the Registered Nurse documented the patient is minimally responsive to verbal stimuli (opens eyes slightly) after unresponsive to tactile stimuli. The Registered Nurse also documented that the Registered Nurse went over hospice philosophies and services with patients primary care givers, and primary caregiver/ Patients daughter signed all consents and election of benefits. Review of the Receipt of Informed Consent for Hospice Services dated 01/09/2024 revealed the form was signed by an individual identified as the primary caregiver. There is no documented evidence that the primary caregiver is the patients authorized representative to authorize the election of hospice care. Review of the Hospice Benefit Election Form dated 01/09/2024 revealed the form was signed by an individual identified as a legal representative. There is no documentation in the clinical record of any individual being named as or identified as the patients legal representative. A. The hospice failed to ensure the hospice election was executed in accordance with State and Federal laws as evidenced by the following: Review of the Consent for Hospices Services form revealed the form contains two parts, Part I is a request that the physician confirm that the patient lacks capacity to request hospice services based on the doctors explanation of the patients diagnosis and prognosis, the patients known wishes, and the son/daughters age. Part I was signed by the patient and hospices representative on 01/09/2024. Part II of the form requires the physician to make a determination of capacity. The form requires the physician and concurring physician to sign and date the form and to attest to a review of the patients medical history and determination based on two choices: that the patient has a terminal condition and lacks capacity to make decisions regarding hospice services or the patient has the ability to understand and appreciate the nature of hospice services including the benefits and disadvantages and to reach informed decision regarding admission to hospice. The form was signed by the hospice physician on 01/24/2024 and signed by the attending physician on 01/24/2024. Additionally, the form is incomplete because there is no documentation that either physician made a determination about the patients capacity. B. The hospice failed to ensure Do Not Resuscitate (DNR) orders were obtained and executed in accordance with State and Federal laws as evidenced by the following: Review of the admission paperwork in the clinical record revealed that the Consent to Do not Resuscitate for an Adult Without Capacity form was initiated. Review of the form revealed it contains two parts: Part I requires the signature of a hospice representative and the patients representative, which requests the physician to attest to the patient not having capacity to request a Do Not Resuscitate Order. Part II of the form requires the physician to examine the patient and make a determination as to whether the patient has capacity to make decisions regarding hospice services and cardiopulmonary resuscitation. Review of the form revealed Part I of the form was signed and dated 01/09/2024 by the hospice Registered Nurse and an individual identified as the patients representative. Part II of the form revealed two physician signature lines, one for the attending, which is signed and undated and one for the concurring physician which is signed and dated by the hospices medical director on 01/24/2024. Additionally, there is no documented evidence the physicians identified on the form the patient by name and determined the patient has decision making capacity regarding cardiopulmonary resuscitation. The hospice failed to ensure an initial determination by an attending practitioner of an adult patients decision-making capacity. During interview on 02/06/2024 at 11:00 AM, the Chief Executive Officer stated that the hospices practice of obtaining copies of advanced directives and capacity statements would have to be reviewed. Patient #8 – This 87-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung was admitted to the hospice on 01/17/2024 and expired on 01/20/2024. This patient was listed on the hospices active patient roster when the roster was requested by the surveyor on 01/22/2024. Review of the Initial Visit dated 01/17/2024 revealed the Registered Nurse documented that the patients orientation was confused- intermittently, cooperative, forgetful, lethargic, minimally responsive, withdrawn. There is no documentation that the patient lacked capacity to make healthcare decisions and there is no evidence of a legally appointed representative. Additionally, there is no documented evidence advance directives were in place at the time of admission, and there is no documented evidence that a physician or concurring physician determined that the patient lacks decision making capacity. Review of the Charts/Clinical Notes dated 01/17/2024 revealed the Registered Nurse documented the patient will be unable to participate in admission process due to weakness and intermittent confusion. Additionally, the Registered Nurse documented that the Registered Nurse explained all consents. Patients son signed all consents as appropriate and also signed Hospice Do Not Resuscitate consent form. Review of the Receipt of Informed Consent for Hospice Services dated 01/17/2024 revealed the form was signed by an individual identified as the primary caregiver. There is no documented evidence that the primary caregiver is the patients authorized representative to authorize the election of hospice care. Review of the Hospice Benefit Election Form dated 01/17/2024 revealed the form was signed by an individual identified as a legal representative. There is no documentation in the clinical record of any individual being named as or identified as the patients legal representative. A. The hospice failed to ensure the hospice election was executed in accordance with State and Federal laws as evidenced by the following: Review of the Consent for Hospices Services form revealed the form contains two parts, Part I is a request that the physician confirm that the patient lacks capacity to request hospice services based on the doctors explanation of the patients diagnosis and prognosis, the patients known wishes, and the son/daughters age. Part I was signed by the patient and hospices representative on 01/17/2024. Part II of the form requires the physician to make a determination of capacity. The form requires the physician and concurring physician to sign and date the form and to attest to a review of the patients medical history and determination based on two choices: that the patient has a terminal condition and lacks capacity to make decisions regarding hospice services or the patient has the ability to understand and appreciate the nature of hospice services including the benefits and disadvantages and to reach informed decision regarding admission to hospice. The form was signed by the hospice physician on 01/26/2024 and signed by the attending physician on 01/26/2024. Additionally, the form is incomplete because there is no documentation that the hospice physician made a determination about the patients capacity. B. The hospice failed to ensure Do Not Resuscitate (DNR) orders were obtained and executed in accordance with State and Federal laws as evidenced by the following: Review of the admission paperwork in the clinical record revealed that the Consent to Do not Resuscitate for an Adult Without Capacity form was initiated. Review of the form revealed it contains two parts: Part I requires the signature of a hospice representative and the patients representative, which requests the physician to attest to the patient not having capacity to request a Do Not Resuscitate Order. Part II of the form requires the physician to examine the patient and make a determination as to whether the patient has capacity to make decisions regarding hospice services and cardiopulmonary resuscitation. Review of the form revealed Part I of the form was signed and dated 01/17/2024 by the hospice Registered Nurse and an individual identified as the patients representative. Part II of the form revealed two physician signature lines, one for the attending, which is signed and dated 01/26/2024 and one for the concurring physician which is signed and dated by the hospices medical director on 01/26/2024, 6 days after the patient expired. Additionally, there is no documented evidence the physicians identified on the form the patient by name and determined the patient has decision making capacity regarding cardiopulmonary resuscitation. Review of the patient record revealed a Nonhospital Order Not to Resuscitate signed and dated by the patients physician on 01/26/2024 (six (6) days after the patient expired). The hospice failed to ensure an initial determination by an attending practitioner of an adult patients decision-making capacity. During interview on 02/06/2024 at 11:00 AM, the Chief Executive Officer stated that the hospices practice of obtaining copies of advanced directives and capacity statements would have to be reviewed. Patient #10 – This 76-year-old patient with a terminal diagnosis of malignant neoplasm of pancreas unspecified was admitted to the hospice on 12/20/2023. Review of the Initial Visit dated 12/20/2023 revealed the Registered Nurse documented that the patients orientation as alert, confused- intermittently, cooperative, forgetful, withdrawn. There is no documentation that the patient lacked capacity to make healthcare decisions and there is no evidence of a legally appointed representative. Additionally, there is no documented evidence advance directives were in place at the time of admission, and there is no documented evidence that a physician or concurring physician determined that the patient lacks decision making capacity. Review of the Charts/Clinical Notes dated 12/20/2023 revealed the Registered Nurse documented the patients wife reported that patient has been telling everyone that his cancer is gone ever since he finished his radiation treatments and that he doesnt feel he needs hospice care. The patients wife requested that the Registered Nurse explain hospice and sign paperwork with her and her daughter in the kitchen, away from the patient. Additionally, the Registered Nurse documented that the Registered Nurse explained all hospice consents. Patients wife signed all consents as appropriate, including the hospice Do Not Resuscitate form. Review of the Receipt of Informed Consent for Hospice Services dated 12/20/2023 revealed the form was signed by an individual identified as the primary caregiver. There is no documented evidence that the primary caregiver is the patients authorized representative to authorize the election of hospice care. Review of the Hospice Benefit Election Form dated 12/20/2023 revealed the form was signed by an individual identified as a legal representative. There is no documentation in the clinical record of any individual being named as or identified as the patients legal representative. A. The hospice failed to ensure the hospice election was executed in accordance with State and Federal laws as evidenced by the following: Review of the Consent for Hospices Services form revealed the form contains two parts, Part I is a request that the physician confirm that the patient lacks capacity to request hospice services based on the doctors explanation of the patients diagnosis and prognosis, the patients best interests, and the patient has a spouse. Part I was signed by the patient and hospices representative on 12/20/2023. Part II of the form requires the physician to make a determination of capacity. The form requires the physician and concurring physician to sign and date the form and to attest to a review of the patients medical history and determination based on two choices: that the patient has a terminal condition and lacks capacity to make decisions regarding hospice services or the patient has the ability to understand and appreciate the nature of hospice services including the benefits and disadvantages and to reach informed decision regarding admission to hospice. The form was signed by the hospice physician on 01/26/2024 and signed and dated by the attending physician on 01/26/2024. Additionally, the form is incomplete because there is no documentation that either physician made a determination about the patients capacity. B. The hospice failed to ensure Do Not Resuscitate (DNR) orders were obtained and executed in accordance with State and Federal laws as evidenced by the following: Review of the admission paperwork in the clinical record revealed that the Consent to Do not Resuscitate for an Adult Without Capacity form was initiated. Review of the form revealed it contains two parts: Part I requires the signature of a hospice representative and the patients representative, which requests the physician to attest to the patient not having capacity to request a Do Not Resuscitate Order. Part II of the form requires the physician to examine the patient and make a determination as to whether the patient has capacity to make decisions regarding hospice services and cardiopulmonary resuscitation. Review of the form revealed Part I of the form was signed and dated 12/20/2023 by the hospice Registered Nurse and an individual identified as the patients representative. Part II of the form revealed two physician signature lines, one for the attending, which is signed and dated 01/26/2024 and one for the concurring physician which is signed and dated by the hospices medical director on 01/26/2024. Additionally, there is no documented evidence the physicians identified on the form the patient by name and determined the patient has decision making capacity regarding cardiopulmonary resuscitation. The hospice failed to ensure an initial determination by an attending practitioner of an adult patients decision-making capacity. During interview on 02/06/2024 at 11:00 AM, the Chief Executive Officer sated that the hospice’s practice of obtaining copies of advanced directives and capacity would have to be reviewed. Public Health Laws Section 2980, 2983 and 2994-C stipulates the following: Section 2980: “;Adult means any person who is eighteen years of age or older, or is the parent of a child, or has married...”;Capacity to make health care decisions” means the ability to understand and appreciate the nature and consequences of health care decisions, including the benefits and risks of and alternatives to any proposed health care, and to reach an informed decision....”;Health care agent” or “;agent” means an adult to whom authority to make health care decisions is delegated under a health care proxy....”;Health care proxy” means a document delegating the authority to make health care decisions, executed in accordance with the requirements of this article...Principal” means a person who has executed a health care proxy.” Section 2981: “;For the purposes of this section, every adult shall be presumed competent to appoint a health care agent unless such person has been adjudged incompetent or otherwise adjudged not competent to appoint a health care agent, or unless a committee or guardian of the person has been appointed for the adult pursuant to article seventy-eight of the mental hygiene law or article seventeen-A of the surrogates court procedure act.” Section 2994-C: Presumption of capacity. For purposes of this article, every adult shall be presumed to have decision-making capacity unless determined otherwise pursuant to this section or pursuant to court order, or unless a guardian is authorized to decide about health care for the adult pursuant to article eighty-one of the mental hygiene law. Initial determination by attending practitioner. An attending practitioner shall make an initial determination that an adult patient lacks decision-making capacity to a reasonable degree of medical certainty. Such determination shall include an assessment of the cause and extent of the patients incapacity and the likelihood that the patient will regain decision-making capacity. Concurring determinations. An initial determination that a patient lacks decision-making capacity shall be subject to a concurring determination, independently made, where required by this subdivision. A concurring determination shall include an assessment of the cause and extent of the patients incapacity and the likelihood that the patient will regain decision-making capacity and shall be included in the patients medical record. Hospitals shall adopt written policies identifying the training and credentials of health or social services practitioners qualified to provide concurring determinations of incapacity. Title 42- Public Health, Chapter IV-Centers for Medicare & Medicaid Services, Part 418, Section 418.3 defines the patients Representative as an “;individual who has the authority under State law (whether by statute or pursuant to an appointment by the courts of the State) to authorize or terminate medical care or to elect or revoke the election of hospice care on behalf of a terminally ill patient who is mentally or physically incapacitated. This may include a legal guardian.” Patient #11 – This 51-year-old patient with the terminal diagnosis of malignant neoplasm of unspecified bronchus or lung was admitted to the hospice on 12/29/2023 and expired on 01/06/2024. This patient was listed on the hospices active patient roster when the roster was requested by the surveyor on 01/22/2024. Review of the Initial Visit dated 12/29/2023 revealed the Registered Nurse documented that the patients orientation could not be assessed because the patient was minimally responsive. There is no documentation that the patient lacked capacity to make healthcare decisions and there is no evidence of a legally appointed representative. Additionally, there is no documented evidence advance directives were in place at the time of admission, and there is no documented evidence that a physician or concurring physician determined that the patient lacks decision making capacity. Review of the Charts/Clinical Notes dated 12/29/2023 revealed the Registered Nurse documented the patient is minimally responsive, and the patients caregiver/son no longer wishes to pursue disease directed treatment for the patient. Additionally, the Registered Nurse documented that the Registered Nurse went over the hospice philosophies and services with the patients caregiver/son who signed all consents, including the hospice election. Review of the Receipt of Informed Consent for Hospice Services dated 12/29/2023 revealed the form was signed by an individual identified as the primary caregiver. There is no documented evidence that the primary caregiver is the patients authorized representative to authorize the election of hospice care. Review of the Hospice Benefit Election Form dated 12/29/2023 revealed the form was signed by an individual identified as a legal representative. There is no documentation in the clinical record of any individual being named as or identified as the patients legal representative. A. The hospice failed to ensure the hospice election was executed in accordance with State and Federal laws as evidenced by the following: Review of the Consent for Hospices Services form revealed the form contains two parts, Part I is a request that the physician confirm that the patient lacks capacity to request hospice services based on the doctors explanation of the patients diagnosis and prognosis, the patients known wishes, and the son/daughters age. Part I was signed by the patient and hospices representative on 12/29/2023. Part II of the form requires the physician to make a determination of capacity. The form requires the physician and concurring physician to sign and date the form and to attest to a review of the patients medical history and determination based on two choices: that the patient has a terminal condition and lacks capacity to make decisions regarding hospice services or the patient has the ability to understand and appreciate the nature of hospice services including the benefits and disadvantages and to reach informed decision regarding admission to hospice. The form was signed by the hospice physician on 01/24/2024 and signed but not dated by the attending physician. Additionally, the form is incomplete because there is no documentation that either physician made a determination about the patients capacity. B. The hospice failed to ensure Do Not Resuscitate (DNR) orders were obtained and executed in accordance with State and Federal laws as evidenced by the following: Review of the admission paperwork in the clinical record revealed that the Consent to Do not Resuscitate for an Adult Without Capacity form was initiated. Review of the form revealed it contains two parts: Part I requires the signature of a hospice representative and the patients representative, which requests the physician to attest to the patient not having capacity to request a Do Not Resuscitate Order. Part II of the form requires the physician to examine the patient and make a determination as to whether the patient has capacity to make decisions regarding hospice services and cardiopulmonary resuscitation. Review of the form revealed Part I of the form was signed and dated by 12/29/2023 the hospice Registered Nurse and an individual identified as the patients representative revealed. Part II of the form revealed two physician signature lines, one for the attending, which is signed and undated and one for the concurring physician which is signed and dated by the hospices medical director on 01/24/2024, 18 days after the patient expired. Additionally, there is no documented evidence the physicians identified on the form the patient by name and determined the patient has decision making capacity regarding cardiopulmonary resuscitation. Review of the patient record revealed a Nonhospital Order Not to Resuscitate signed and dated by the patients Nurse Practitioner on 01/25/2024 (nineteen (19) days after the patient expired). The hospice failed to ensure an initial determination by an attending practitioner of an adult patients decision-making capacity. During interview on 02/06/2024 at 11:00 AM, the Chief Executive Officer stated that the hospices practice of obtaining copies of advanced directives and capacity statements would have to be reviewed.”

“Based on review of clinical records, agency policy and procedures and interviews with staff, the hospice failed to ensure in three (3) of sixteen (16) clinical records (Patient #s: 1, 7, and 9) the content of the comprehensive assessment is of sufficient scope to identify all of the patient’s needs in order to promote the patient’s well-being and comfort throughout the dying process. Specifically, assessments were incomplete and did not include a complete assessment of the patient’s skin integrity/wounds (Patient #1 and 9) and the patient’s colostomy and colostomy site (Patient #7). Failure to ensure assessments are comprehensive has the potential for unmet patient needs and the likelihood of patient harm. Review of the agencys policy entitled “;Basic Wound Care” review dated 03/30/2023 revealed “;All wounds are to be documented on the initial comprehensive assessment, and every routine assessment thereafter, including wound location, size, description of appearance (including wound edges and surrounding tissue), stage of healing, and patient level of comfort or discomfort. Wounds are to be measured with a paper measuring tape for length, width as well as approximated depth (if there is no measurable depth- it must be stated or documented as 0)...” Patient #1- This 102-year-old patient with the terminal diagnosis malignant neoplasm of bladder, unspecified was admitted to the hospice on 09/12/2022. Review of the Initial Visit dated 09/12/2022 the Registered Nurse documented the patient has a superficial left buttock wound, measuring 0.5 centimeters long and 0.5 centimeters wide. The agency failed to measure wounds, to include a length, width and depth. During interview on 02/08/2024 at 11:27 AM, the Former Registered Nurse Care Coordinator stated that “;It was a superficial wound, theres no depth listed. But I should have put zero (0) depth. Review of the agencys policy entitled “;Admission of Patient for Hospice Services” review dated 09/14/2023 revealed “;Procedure: ... 5. An admission visit is conducted on those individuals meeting diagnostic and prognostic criteria. This visit includes the following... D. The completion of a comprehensive assessment, including assessment of physical, psychosocial, medical, nutritional, and environmental needs, which is documented in the Electronic Medical Record...” Patient #7- This 64-year-old patient with the terminal diagnosis malignant neoplasm of colon, unspecified was admitted to the hospice on 01/04/2024. Review of the Initial Visit dated 01/04/2024 revealed the Registered Nurse documented the following: Medical/ Surgical/ Habits History: Surgical History: Description, Tonsillectomy, lower anterior resection of the rectum, colostomy, exploratory laparoscopy. Physical/ Gastrointestinal: Last Bowel Movement: 01/03/2024 Gastrointestinal Assessment: Bowel Sounds- Present, Bowel Regimen- Uses toilet Details: Not Applicable. The comprehensive assessment lacked documented evidence the Registered Nurse completed an assessment of the patients colostomy site. During interview on 02/06/2024 at 10:28 AM the Registered Nurse Care Coordinator stated that the patients skin was assessed, but the Registered Nurse did not document an assessment of the colostomy site. The Registered Nurse stated that the missing documentation was identified during the interview. Additionally, there is a place in the medical record for the Registered Nurse to document an assessment of the colostomy, but it was not completed. Furthermore, the Registered Nurse stated that it is the agencys expectation to identify the colostomy site and characteristics of the colostomy. Review of the agencys policy entitled “;Basic Wound Care” last reviewed on 03/30/2023 revealed, “;All wounds are to be documented on the initial comprehensive assessment, and every routine assessment thereafter, including wound location, size, description of appearance (including wound edges and surrounding tissue), stage of healing, and patient level of comfort or discomfort. Wounds are to be measured with a paper measuring tape for length, width as well as approximated depth (if there is no measurable depth- it must be stated or documented as 0...” Patient #9 – This 90-year-old patient with the terminal diagnosis of unspecified diastolic (congestive) heart failure was admitted to the hospice on 01/04/2024. Review of the On call/Unscheduled Visit dated 01/11/2024 revealed the Registered Nurse documented the patient has a stage 2 pressure ulcer on her right upper buttocks measuring 0.6 centimeters long and 0.9 centimeters wide. The agency failed to measure wounds, to include a length, width, and depth. During interview on 02/06/2024 at 10:15 AM, the Senior Registered Nurse Care Coordinator stated wounds should have a depth documented. The Senior Registered Nurse Care Coordinator stated there was no depth to this wound so she should have documented a depth of zero centimeters.”

“Based on review of clinical records and interviews with staff for one (1) of sixteen (16) clinical records (Patient #: 14), the hospice failed to provide services according to the Plan of Care. Specifically, the hospice failed to provide skilled nursing services at the ordered frequency. Failure to provide services in accordance with the Plan of Care has the potential for unmet patient needs. Patient #14- This 89- year- old patient with the terminal diagnosis of heart failure, unspecified was admitted to the hospice on 12/11/2023. Review of the Physicians Orders/ Plan of Care dated 12/11/2023 revealed the order for skilled nursing two (2) times a week for twelve (12) weeks. Review of the clinical record from 12/11/2023 to 01/24/2024 revealed the Registered Nurse visited the patient on 12/11/2023, 12/21/2023, 01/04/2024, 01/19/2024, and 01/23/2024. There is a lack of documented evidence of two skilled nursing visits a week as ordered. The hospice failed ensure services are provided in accordance with the Plan of Care. During interview on 02/06/2024 at 10:45 AM, the Registered Nurse Care Coordinator stated that the correct nursing frequency is one visit every two weeks, and the wrong frequency was entered in error.”

“Based on review of clinical records and interviews with staff for nine (9) of sixteen (16) patients (Patient #s: 2, 3, 4, 5, 8, 9, 10, 11, and 13), the hospice failed to develop an individualized written Plan of Care that reflects the patient and family goals and is based on the problems identified in the initial and updated comprehensive assessments. Specifically, plans of care are incomplete and lacked orders for services needed, treatments, durable medical equipment, and medications. Additionally, plans of care lacked all pertinent diagnoses, orders to discontinue blood glucoses, and are not updated to include only current medications. Furthermore, a plan of care included an order for Benadryl, a medication that the patient was allergic to. Failure to ensure plans of care are individualized, kept current and reflect the patient’s needs has the potential for unmet patient needs and health status to be compromised, resulting in poor quality of care. Patient #5- This 63- year- old patient with the terminal diagnosis of malignant neoplasm of the pancreas, unspecified was admitted to the hospice on 10/16/2023. A.) Review of the Prognostic Checklist dated 10/16/2023 revealed the patients diagnoses include the following: cancer (type not specified), pancreatitis, and hypertension. Review of the Initial Visit dated 10/16/2023 revealed the following Medical History: Anemia, Hypertension, Other: Malignant neoplasm to right bronchial lung. Review of the Physicians Orders/ Plan of Care dated 10/16/2023 lacked documented evidence of the following diagnoses: pancreatitis, hypertension, anemia, malignant neoplasm to the right bronchial lung. During interview on 02/08/2024 at 10:40 AM, the Registered Nurse Care Coordinator stated that the diagnoses on the Prognostic Checklist should be the same as those on the assessment. The agencys Administrative Assistant is responsible for entering the diagnoses into the system so that they are listed in the plan of care. B.) Review of the Team Care Plan dated 01/2/2024 revealed the patient receives Skilled Nursing, Home Health Aide, Medical Social Worker, Spiritual Care and Volunteer services. Review of the Physicians Orders/ Plan of Care dated 01/14/2024 lacked orders for Skilled Nursing, Home Health Aide, and Medical Social Worker services. During interview on 02/08/2024 at 10:25 AM, the Chief Nursing Officer stated that there are no orders for Skilled Nursing, Home Health Aide, and Medical Social Worker services. Patient #10 – This 76-year-old patient with the terminal diagnosis of malignant neoplasm of pancreas unspecified was admitted to the hospice on 12/20/2023. A.) Review of the Prognostic Checklist dated 12/202/2023 revealed the patients diagnoses include: sleep apnea, atrial fibrillation, low back pain, polyneuropathy, carpel tunnel, adjustment disorder (anxiety/ depression), non-insulin dependent diabetes mellitus, dysarthria, morbid obesity, atherosclerosis, impaired mobility, chronic kidney disease stage 3, dependent edema, bilateral hip pain, history of a pacemaker, hyperparathyroidism, and three other illegible diagnoses. Review of Initial Visit dated 12/20/2023 revealed the following Medical History: Anxiety, Coronary artery disease, Cancer, Depression, Diabetes, Falls, Hyperlipidemia, Obese, Peripheral neuropathy, Other: Hyperparathyroidism, Bradycardia, Dysarthria, Dependent edema, Carpal tunnel syndrome, Cervical spine stenosis, Chronic kidney disease Stage 3, Spinal stenosis. Review of the Physicians Orders/ Plan of Care dated 12/20/2023 lacked documented evidence of the following diagnoses: sleep apnea, atrial fibrillation, low back pain, polyneuropathy, carpel tunnel, adjustment disorder (anxiety/ depression), non-insulin dependent diabetes mellitus, dysarthria, morbid obesity, atherosclerosis, impaired mobility, chronic kidney disease stage 3, dependent edema, bilateral hip pain, history of a pacemaker, hyperparathyroidism, falls, hyperlipidemia, hyperparathyroidism, bradycardia, cervical spine stenosis, and spinal stenosis. During interview on 02/06/2024 at 04:03 PM, the Senior Registered Nurse Care Coordinator stated that the agencys Administrative Assistant is responsible for entering the patients diagnoses into the plan of care, and the plan of care is missing all listed diagnoses for this patient. B.) Review of the Initial Visit dated 12/20/2023 revealed Medication Evaluation: Medication Reconciliation: Medications reconciled without issue. Review of the Chart/ Clinical Notes dated 12/20/2023 revealed the Registered Nurse documented the patients medication orders include: Ketoconazole 2% shampoo once daily and Calcium Carbonate 500 milligrams, two (2) chewable tablets three times daily as needed. Review of Physicians Orders/ Plan of Care dated 12/20/2023 lacked an order for Ketoconazole 2% shampoo and Calcium Carbonate. Review of the Team Care Plan dated 01/25/2024 lacked an order for Ketoconazole 2% shampoo and Calcium Carbonate. The hospice failed to ensure the plan of care is complete and lists all current medications. During interview on 02/06/2024 at 03:58 PM, the Senior Registered Nurse Care Coordinator stated that the Ketoconazole and Calcium Carbonate were ordered, but they were not listed on the medication list. The Senior Registered Nurse Care Coordinator stated that “;this was an oversight.” Patient #3- This 76-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified part of the right bronchus or lung was admitted to the hospice on 01/09/2024. Review of the clinical record from 01/09/2024 to 01/24/2024 revealed the Registered Nurse completed two on-call/ unscheduled visits to the patients home on 01/15/2024 and 01/24/2024. Review of the Physicians Orders/ Plan of Care dated 01/09/2024 revealed there are no orders for as needed/on-call/unscheduled Skilled Nursing visits. During interview on 02/08/2024 at 09:50 AM, the Registered Nurse Care Coordinator stated that the Skilled Nursing frequency is every two (2) weeks and as needed. During interview on 02/08/2024 at 09:53 AM, the Chief Nursing Officer stated that there are no orders for the as needed Skilled Nursing visits. Patient #8 – This 87-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung was admitted to the hospice on 01/17/2024 and expired on 01/20/2024. This patient was listed as an active patient when the surveyor requested the active patient roster on 01/22/2024. Review of the Initial Visit dated 01/17/2024 revealed the Registered Nurse documented that the patient has a “;right flank/ rib cage pleurex drain. Dressing intact over area. Family did not want patients tube drained today during admission visit. Family stated the Visiting Nursing Association nurse had visited earlier this morning and did not feel patient needs it drained any longer due to having decreased fluid out the last few times it has been drained and patient not experiencing any pain in that area or shortness of breath. They dont want to disturb the patient since the patient appears comfortable.” Review of Physicians Orders/ Plan of Care dated 01/17/2024 revealed there is no order for draining/maintaining the pleurex drain and no orders for dressing changes at the Pleurex drain site. The hospice failed to ensure the plan of care is complete and reflects the patients current needs. During interview on 02/06/2024 at 04:18 PM, the Senior Registered Nurse Care Coordinator stated that there are no orders for Pleurex drain and dressing changes. Patient #12- This 84- year- old patient with a terminal diagnosis of malignant neoplasm of left renal pelvis was admitted to the hospice on 01/08/2024 and expired on 01/17/2024. This patient was listed on the hospices active patient roster when the roster was requested by the surveyor on 01/22/2024. This patient was transferred to the hospice from another hospice. Review of Client Coordination Note Report from the previous hospice dated 10/27/23 revealed the hospice physician documented that Metformin was discontinued months earlier at the patients request and weekly random blood sugars remain controlled. Review of the Initial Visit dated 01/08/2024 revealed the Registered Nurse documented that the patient has well controlled diabetes and does not test blood sugars. Review of the Physicians Orders/ Plan of Care dated 01/08/2024 lacks an order for diabetic management to include whether the patient monitors blood glucoses. During interview on 02/08/2024 at 01:15 PM, the Registered Nurse Care Coordinator stated that there were no diabetic directives on the orders. Patient #13 – This 85-year-old patient with the terminal diagnosis of malignant neoplasm of the uterus, part unspecified was admitted to the hospice on 01/18/2024. A. Review of the Prognostic Checklist dated 01/18/2024 revealed the patient’s diagnoses include the following: cancer (type not specified), retinal artery branch occlusion, anxiety, seborrheic keratoses, osteoarthritis, multiple benign melanocytic nevi of the upper and lower extremities and trunk, depression, hyperlipidemia, vitamin d deficiency, lentigo, and thyroid nodule. Review of the Physician’s Orders/Plan of Care dated 01/18/2024 lacked documented evidence of the following diagnoses: retinal artery branch occlusion, anxiety, seborrheic keratoses, osteoarthritis, multiple benign melanocytic nevi of the upper and lower extremities and trunk, depression, hyperlipidemia, vitamin d deficiency, lentigo, and thyroid nodule. During interview on 02/07/2024 at 02:07 PM, the Nursing Services Manager stated not all of the diagnoses listed on the prognostic checklist are on the patients plan of care and they should be. B. Review of the Physicians Attestation dated 01/19/2024 revealed the hospice Interdisciplinary Team physician attested to having completed a comprehensive review of the admission medication list, offered no recommendations, and listed allergies to Diphenhydramine (Benadryl), Clarithromycin, Biaxin, and Mitomycin. Review of the Medication List dated 01/18/2024 list allergies to Diphenhydramine (Benadryl), Clarithromycin, Biaxin, and Mitomycin. Review of the Physicians Orders/Plan of Care dated 01/18/2024 revealed the following: - Allergies: Diphenhydramine (Benadryl), Clarithromycin, Biaxin, and Mitomycin, and - Standing Orders: Diphenhydramine (Benadryl) 25 milligrams, 1 – 2 tablets by mouth every four (4) hours as needed for pruritis. The plan of care included an order for a medication the patient has a documented allergy to. Specifically, Diphenhydramine (Benadryl). The hospice failed to develop an individualized written Plan of Care that reflects the patient and family goals and is based on the problems identified in the initial comprehensive assessment. During interview on 02/07/2024 at 02:09 PM, the Nursing Services Manager stated Diphenhydramine (Benadryl) should not have been selected as an option in the standing orders due to the patients allergy to Benadryl. C. Review of the Charts/Clinical Notes effective 01/18/2024 revealed the Registered Nurse documented the patient was in the hospital a few weeks ago due to uterine bleeding that would not stop. Additionally, the Registered Nurse documented that at the time of the hospitalization the patient was on Eliquis which was stopped at that time due to the possibility of more bleeding. Review of the Physicians Orders/Plan of Care dated 01/18/2024 revealed an order for Eliquis, 5 milligrams by mouth, twice daily for atrial fibrillation. The plan of care include an order for a medication the patient is no longer taking. Specifically, Eliquis. The hospice failed to develop an individualized written Plan of Care that reflects the patient and family goals and is based on the problems identified in the initial comprehensive assessment. During interview on 02/07/2024 at 02:10 PM, the Nursing Services Manager stated she would look to see if the plan of care updated. The Nursing Services Manager stated the patient stopped and started the Eliquis both on the same day so there may be a supplemental order. As of exit, no further information was provided to refute the findings. Patient #4 – This 72-year-old patient with the terminal diagnosis of malignant neoplasm of the colon, unspecified was admitted to the hospice on 01/23/2024. A. Review of the Initial Visit dated 01/23/2024 revealed the Registered Nurse documented the patient stopped all medications with the exception of the comfort pack medications (Morphine Sulfate, Lorazepam, and Levsin), trazadone for insomnia, and duloxetine for his depression/anxiety issues. Review of the Charts/Clinical Notes with an effective date of 01/23/2024 revealed the Registered Nurse documented the patient and patient’s caregiver wanted to stop everything but the comfort pack medications (Morphine Sulfate, Lorazepam, and Levsin), Trazadone, Fluoxetine, and Senna. Review of the Physicians Orders/Plan of Care dated 01/23/2024 revealed the patient was ordered the following medications: - Comfort pack medications (Morphine Sulfate, Lorazepam, and Levsin); - Amlodipine for hypertension; - Dexamethasone for swelling; - Duloxetine for depression; - Dutasteride for hypertension; - Pantoprazole for gastroesophageal reflux disease; - Senna for constipation; - Silodosin for urinary retention; and - Trazadone for insomnia. The plan of care included orders for medications the patient is no longer taking. Specifically, Amlodipine, Dexamethasone, Dutasteride, Pantoprazole, and Silodosin. The hospice failed to develop an individualized written Plan of Care that reflects the patient and family goals and is based on the problems identified in the initial comprehensive assessment. During interview on 02/07/2024 at 01:30 PM, the Nursing Services Manager stated those medications should have been discontinued and not included on the patients plan of care because the patient was no longer taking them. B. Review of the Prognostic Checklist dated 01/23/2024 revealed the patient’s diagnoses include the following: congestive heart failure, diabetes mellitus, gastroesophageal reflux disease, benign prostatic hyperplasia, cancer (type not specified), prostate cancer, anxiety, depression, hypertension, chronic embolism and thrombosis of the vein, colostomy, and atherosclerosis. Review of the Physician’s Orders/Plan of Care dated 01/23/2024 lacked documented evidence of the following diagnoses: congestive heart failure, diabetes mellitus, gastroesophageal reflux disease, benign prostatic hyperplasia, prostate cancer, anxiety, depression, hypertension, chronic embolism and thrombosis of the vein, colostomy, and atherosclerosis. During interview on 02/07/2024 at 01:15 PM, the Nursing Services Manager stated it is the responsibility of the Registered Nurse to give the prognostic checklist to the Administrative Assistant so that they can add all of the diagnoses to the patients the plan of care. The Nursing Services Manager stated that because she had not given the prognostic checklist to the Administrative Assistant the Administrative Assistance had not been able to include the diagnoses on the patients plan of care. Patient #11 - This 51-year-old patient with the terminal diagnosis of malignant neoplasm of unspecified bronchus or lung was admitted to the hospice on 12/29/2023 and expired on 01/06/2024. This patient was listed on the hospices active patient roster when the roster was requested by the surveyor on 01/22/2024. A. Review of the Prognostic Checklist dated 12/29/2023 revealed the patient’s diagnoses include the following: neoplasia, heart murmur, hypercholesterolemia, hypertension, hiatal hernia, obesity, and cholecystectomy. Review of the Physician’s Orders/Plan of Care dated 12/29/2023 lacked documented evidence of the following diagnoses: heart murmur, hypercholesterolemia, hypertension, hiatal hernia, obesity, and cholecystectomy. During interview on 02/07/2023 at 02:30 PM, the Registered Nurse Care Coordinator stated once the prognostic checklist gets filled out by the nurse it is given to the Administrative Assistant to add the diagnoses and this was not done. B. Review of the Initial Visit dated 12/29/2023 revealed the Registered Nurse documented the patient is incontinent of urine and uses extra-large, tabbed briefs. Review of the Physicians Orders/Plan of Care dated 12/29/2023 lacked an order for incontinent supplies, specifically extra-large, tabbed briefs. During interview on 02/07/2023 at 02:35 PM, the Registered Nurse Care Coordinator stated the briefs are not on the patients plan of care because she did not know this was required but that she will be sure to add them going forward. Patient #2 – This 68-year-old patient with the terminal diagnosis of malignant neoplasm of the colon, unspecified was admitted to the hospice on 01/03/2024. Review of the Prognostic Checklist dated 01/03/2024 revealed the patient’s diagnoses include the following: neoplasia, colon cancer, hypertension, pulmonary emboli, bowel obstruction, and superficial thrombosis of the leg. Review of the Physician’s Orders/Plan of Care dated 01/03/2024 lacked documented evidence of the following diagnoses: hypertension, pulmonary emboli, bowel obstruction, and superficial thrombosis of the leg. During interview on 02/07/2024 at 03:10 PM, the Registered Nurse Care Coordinator stated the diagnoses on the prognostic checklist are not on the patients plan of care and the Administrative Assistant should have added them to the plan of care. Patient #9 – This 90-year-old patient with the terminal diagnosis of unspecified diastolic (congestive) heart failure was admitted to the hospice on 01/04/2024. Review of the Prognostic Checklist dated 01/04/2024 revealed the patient’s diagnoses include the following: congestive heart failure, coronary artery disease, hypertension, atrial fibrillation, hyperlipidemia, non-insulin dependent diabetes mellitus, right pleural effusion, diverticulosis, myocardial infarction, coronary artery bypass graft, coronary stent, gastroesophageal reflux disease, renal disease, and a pacemaker. Review of the Physician’s Orders/Plan of Care dated 01/03/2024 lacked documented evidence of the following diagnoses: coronary artery disease, hypertension, atrial fibrillation, hyperlipidemia, non-insulin dependent diabetes mellitus, right pleural effusion, diverticulosis, myocardial infarction, coronary artery bypass graft, coronary stent, gastroesophageal reflux disease, renal disease, and a pacemaker. During interview on 02/06/2024 at 09:45 AM, the Senior Registered Nurse Care Coordinator stated when the Administrative Assistant receives the completed prognostic checklist, they put all the diagnoses into the patients plan of care, and in this case the diagnoses were not put in.”

“Based on review of clinical records and interviews with staff, for five (5) of sixteen (16) clinical records (Patients #s: 4, 6, 8, 11, and 14) lacked evidence that plans of care are developed to include goals, interventions and measurable individualized outcomes anticipated from implementing and coordinating the plan of care. Failure to incorporate goals, interventions and measurable outcomes in the plan of care provides the Hospice with no mechanism to determine if interventions identified have been effective in movement toward patient goals and has the potential to result in unmet patient needs. Patient #6- This 82- year- old patient with a terminal diagnosis of End Stage Renal Disease was admitted to the hospice on 01/08/2024. A.) Review of the Initial Visit dated 01/08/2024 revealed the Registered Nurse documented that the patient was fatigued, had household endurance only and required assistance/ supervision for gait. Review of the Team Care Plan dated 01/24/2024 revealed the plan of care problem “;Alteration in Activities of Daily Living” was identified. However, there is a lack of interventions to meet the identified goals or specific individualized measurable outcomes. B.) Review of the Initial Visit dated 01/08/2024 revealed the Registered Nurse documented under Bereavement/ Grief Risk Factors that the patient had difficulty with previous losses. Review of the Team Care Plan dated 01/24/2024 revealed the plan of care problem “;Preterminal Care” was identified. However, there is a lack of interventions to meet the identified goals or specific individualized measurable outcomes. During interview on 02/07/2024 at 11:48 AM, the Senior Registered Nurse Case Coordinator stated that they can see the goals but did see interventions. That they need to check them off, but there are none in the system and they must have forgotten them. Patient #14- This 89- year- old patient with terminal diagnosis of heart failure, unspecified was admitted to the hospice on 12/11/2023. A.) Review of the Initial Visit dated 12/11/2023 revealed the Registered Nurse documented that the patient has fatigue and activity intolerance. Review of the Team Care Plan dated 01/24/2024 revealed the problem “;Alteration in Activities of Daily Living” was identified. The short-term goals identified include the ability to perform/ participate in Activities of Daily Living and to demonstrate safe, effective use of adaptive devices. The Long-term goals identified include the demonstration of ability to perform Activities of Daily Living within the limits of the disease process and maintaining safety. There are no interventions to meet the identified goals or specific individualized measurable outcomes. During interview on 02/06/2024 at 10:54 AM, the Registered Nurse Care Coordinator spoke with the surveyor via telephone and stated that the interventions are listed in the Team Care Plan, and could be visualized by the Registered Nurse Coordinator. Additionally, the Registered Nurse Coordinator was unsure why the interventions do not print out. The Registered Nurse Care Coordinator said the interventions would be printed and provided to the surveyor. As of exit, no further documentation was provided to refute the findings. B.) Review of the Team Care Plan dated 12/11/2023 revealed the Team Care Plan problem “;Fall Protocol” was identified. No goals are documented. Interventions include encouraging the patient to change position slowly and evenly, using mobility aides as necessary and make sure footwear fits well when ambulating, keeping walkways uncluttered, keeping the patients bed in low position when not providing care, and frequently checking on the patient or providing constant supervision through family, friends or other support. Review of the Charts/ Clinical Notes dated 01/04/2024 revealed the Registered Nurse documented that the patients caregiver reported that the patient was weak that morning and needed to be lowered to the floor and that patient is also still getting up when no one is in the room. Review of the Charts/ Clinical Notes dated 01/23/2024 revealed the Registered Nurse documented a telephone call from the patients daughter reporting that the patient had fallen in the morning on 01/22/2024 and initially complained of some hip pain but was able to walk normally. Later, when the patient woke up, the patient was unable to walk and was again complaining of hip pain. Review of the Team Care Plan dated 01/24/2024 revealed the Team Care Plan was not updated to include new interventions to address the patients falls and pain. During interview on 02/06/2024 at 11:12 AM, the Registered Nurse Care Coordinator stated that a bed/ chair alarm was taken to the home on 01/04/2024 but this was not documented. Additionally, there are no goals listed on the care plan to address the identified fall protocol problem. Patient #8 – This 87-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung was admitted to the hospice on 01/17/2024 and expired on 01/20/2024. This patient was listed on the hospices active patient roster when the roster was requested by the surveyor on 01/22/2024. Review of the Team Care Plan dated 01/17/2024 revealed the Team Care Plan problem “;Alteration in Respiratory System” was identified. However, the plan of care does not address the patients pleurex drain and does not include goals, interventions or specific individualized measurable outcomes. During interview on 02/06/2024 at 04:26 PM, the Senior Registered Nurse Care Coordinator stated that there were no goals or interventions for the pleurex drain. Patient #11 - This 51-year-old patient with the terminal diagnosis of malignant neoplasm of unspecified part of the unspecified bronchus or lung was admitted to the hospice on 12/29/2023 and expired on 01/06/2024. This patient was listed on the hospices active patient roster when the roster was requested by the surveyor on 01/22/2024. Review of the Charts/Clinical Notes effective 01/05/2024 revealed the Licensed Practical Nurse documented she inserted a 16 French Foley catheter with a 10 cubic centimeter balloon. Review of the Team Care Plan dated 01/05/2024 revealed the problem “;Alteration in the Genitourinary System” was identified. However, the care plan does not address the patient’s urinary catheter and does not include goals, interventions, or specific individualized measurable outcomes. During interview on 02/08/2024 at 02:45 PM, the Chief Nursing Officer stated there are no goals, interventions, or specific individualized measurable outcomes specific to the indwelling urinary catheter. Patient #4 – This 72-year-old patient with the terminal diagnosis of malignant neoplasm of the colon, unspecified was admitted to the hospice on 01/23/2024. Review of the Charts/Clinical Notes effective 01/25/2024 revealed the Licensed Practical Nurse documented she inserted an 18 French Foley catheter with a 10 cubic centimeter balloon. Review of the Team Care Plan dated 01/25/2024 revealed the care plan lacked documented evidence of a Genitourinary System problem. Additionally, the care plan does not address the patient’s urinary catheter and does not include goals, interventions, or specific individualized measurable outcomes. During interview on 02/08/2024 at 02:33 PM, the Chief Nursing Officer stated she would look for an updated plan of care. As of exit, no further information was provided to refute the findings.”

“Based on clinical record review, agency policy and procedure, and interview with agency staff, two (2) of sixteen (16) clinical records (Patient #s 9 and 19), lacked documented evidence the hospice maintained a system of communication and integration to ensure that the Interdisciplinary Group had an accurate and timely assessment of the patient/family status to evaluate the effectiveness of the comprehensive Hospice Plan of Care. Lack of communication has the potential for unmet identified patient needs. Review of the agency policy entitled “;Interdisciplinary Team” last reviewed on 09/14/2023 revealed the following, “;2) The roles of the interdisciplinary teams include: b) Determination of admission eligibility and appropriate continuation of hospice services; d) Timely communication among members as the patients condition changes and new needs are identified...” Patient #19 – This 64-year-old patient with the terminal diagnosis of malignant neoplasm of the lung was admitted to the hospice on 01/09/2024, revoked the hospice benefit on 01/18/2024, and was discharged on 01/18/2024. Review of the Charts/Clinical Notes with an effective date of 01/15/2024 (Monday) and signed and dated by the Registered Nurse on 01/15/2024 12:24 PM revealed the Registered Nurse documented that the patient continues to reside at home alone, he does not have family in the area, and he does not have anyone to be a 24/7 caregiver. The Registered Nurse stated the hospice received a telephone call from the patients sister who resides in Switzerland this morning. The patients sister informed the Registered Nurse that she had called the hospice twice in the past twelve hours to report that the patient has been “;out of it.” During the call, the patients sister requested the hospice conduct a welfare check of the patient. Following the call from the patients sister, the Registered Nurse and Social Worker made a co-visit to the patient and found the patient to be confused and unsteady on his feet. The Registered Nurse stated that the patient stated, “;he feels his dizziness is related to his medications.” The patient showed the Registered Nurse that he has been taking a “;full syringe” of the liquid Morphine three times and day and he has one third of the bottle of Morphine left. The Registered Nurse stated that “;it appears he has taken too much of his medications and needs better medication management and supervision.” The Registered Nurse stated that she would take a pill box to the patients home and set it up that afternoon. The Registered Nurse stated that despite setting up the pill box she feels “;the situation still appears unsafe for the patient to remain home alone.” The Registered Nurse stated that the patient agrees with having a pill box to manage his medications. Lastly, the Registered Nurse stated she is “;unsure if the patient will be complaint with the use of a pill box”, but she will set it up that day. Review of the Charts/Clinical Notes with an effective date of 01/15/2024 (Monday) and signed and dated by the Registered Nurse on 01/16/2024 at 12:55 PM revealed the Registered Nurse made a second visit to the patient on 01/15/2024 to provide and set up a pill minder. The Registered Nurse stated that when she arrived at the patients home, she found the patient to be unsteady on his feet, holding onto doorways and furniture, and refusing to use his walker. The Registered Nurse stated the patient had pill bottles in all rooms of the house, she assisted the patient with locating all of his pill bottles, and she filled the pill box. The Registered Nurse stated that the patient continues to have confusion, kept mixing up his words, and appeared to have difficulty working his phone. The Registered Nurse also stated that the patient had “;difficulty sitting still.” During the visit, the patients sister called from Switzerland to check on the patient. The Registered Nurse spoke with the patients sister and informed her of the patients current condition and confusion. The Registered Nurse informed the sister that the patients confusion is “;possibly related to how the patient has been taking his medications.” The Registered Nurse informed the patients sister that the patient has been taking one (1) milliliter of liquid Morphine approximately three (3) times per day and that she instructed the patient to decrease his dose to 0.5 milliliters (frequency not specified). The Registered Nurse stated that she and the patient discussed the patients safety concerns, his increased confusion, and the option of going to a comfort home. Following the discussion, the Registered Nurse stated that the patient agreed to go to the comfort home. The Registered Nurse stated she contacted the Social Worker, and they discussed the concerns about the patient remaining home alone. At this time, the Registered Nurse requested the Social Worker contact the comfort home to see if they were able admit the patient on that day or the following day. The Registered Nurse stated that the Social Worker contacted the comfort home, but they would not be able to admit the patient until Wednesday. The Registered Nurse stated she reassured the patient he would not be going to the comfort home until Wednesday. The Registered Nurse stated she “;left from the visit with the patient stating he is going to bed and rest for a while.” The Registered Nurse stated the patient stated he is “;very tired” from not sleeping well last night. Lastly, the Registered Nurse stated she is “;still concerned about patient remaining at home without any supervision.” Review of the Charts/Clinical Notes with an effective date of 01/15/2024 and signed by the Social Worker on 01/15/2024 at 02:42 PM revealed that the Social Worker was informed by the Registered Nurse that the patients sister had contacted the Registered Nurse to report that the patient was “;out of it.” Following the phone call from the patients sister, the Social Worker and the Registered Nurse conducted a co-visit to the patient’s home. Upon arrival to the patients home the Social Worker stated the patient was alert, not oriented to time, confused, and “;wobbly on his feet.” The Social worker stated that patient “;feels that his dizziness is due to the medications he has been taking.” The Social Worker stated that the Registered Nurse believes that the patient has taken too many medications, and this has been affecting the patients mental status. The Social Worker stated that the patient is agreeable to an admission to the comfort home, but he is not ready to go at this time. The Social worker stated she encouraged the patient to stay in bed and try to sleep to avoid falls. Review of the Charts/Clinical Notes with an effective date of 01/15/2024 and signed and dated by the Registered Nurse on 01/16/2024 at 12:55 PM revealed the Registered Nurse called the hospice Chief Nursing Officer to discuss the Registered Nurses concerns over the patients safety. The Registered Nurse stated the Chief Nursing Officer instructed her to contact the patient and ask the patient if he was willing to go to the hospital for symptom management until the comfort care home could admit him. The Registered Nurse stated she contacted the patient, and the patient is agreeable to going to the hospital “;just this once.” Lastly, the Registered Nurse stated she contacted the Social Worker, and the Social Worker will be contacting the hospitals to find a bed for the patient to be admitted. Review of the Charts/Clinical Notes with an effective date of 01/15/2024 and signed by the hospice On-Call Registered Nurse on 01/16/2024 at 11:18 AM, revealed the hospice On-Call Registered Nurse documented a series of entries starting at 04:45 PM. At 04:45 PM the initial call was received by the hospice On-Call Registered Nurse in which the hospices answering service was informing the hospice On-Call Registered Nurse that the patients friend called the answering service to get in touch with a specific hospice nurse to get an update on the patient. At 5:03 PM, a second phone call was received from the hospices answering service informing the hospice that the patients friend had just arrived at the patients home and the patient was in “;really bad shape.” At 05:08 PM the hospice On-Call Registered Nurse contacted the patients friend. The friend stated that he wanted to know what was going on with the patient and whether the patient would be going to the hospital. During the conversation, the friend also inquired to know if the patient was going to the hospital by ambulance and if the ambulance was not going to pick him up someone was “;going to have to come out and help with the patient” The friend stated that the patient was confused and “;even threatened to overdose.” At 05:54 PM a Registered Nurse from the hospice called the hospice On-Call Registered Nurse to report that the patient was refusing to go to the hospital and that there was a comment about “;overdosing” and the hospice Registered Nurse was “;passing this information on to” the Social Worker. At 06:25 [no documentation as to whether the entry was AM or PM] the hospice On-Call Registered Nurse called the patients friend who stated that the ambulance was at the patients home, but the patient was refusing to go to the hospital, and the Emergency Medical Technicians were not going to take the patient to the hospital. The patients friend also reported that the patient told the patients friend to leave, and the patients friend was sitting in his car next to the ambulance. The hospice On-Call Registered Nurse asked the friend if the friend told the Emergency Medical Technicians about the patients threat to overdose. The patients friend told the hospice On-Call Registered Nurse that he did not because the patients friend thought it was a “;passing comment.” The hospice On-Call Registered Nurse documented that she spoke with the Emergency Medical Technician, who told the hospice On-Call Registered Nurse that the patient did not seem confused and is refusing transport, so they could not take him. The hospice On-Call Registered Nurse reported she informed the Emergency Medical Technician that the patient threatened to overdose himself and the hospice On-Call Registered Nurse recommended to the Emergency Medical Technician look into these statements more before leaving. The Emergency Medical Technician reported that the patient kicked the Emergency Medical Technicians out and slammed the door in their faces, and the Emergency Medical Technicians could not evaluate further. The hospice On-Call Registered Nurse documented that she spoke with the patients friend who asked for a hospice nurse to come out and assess the patient that evening. The hospice On-Call Registered Nurse told the friend that a Registered Nurse would call the patient in “;a little while after he [the patient] has had a chance to calm down a bit but if the pt [patient] is agreeable to her visiting tonight she will do so.” The hospice On-Call Registered Nurse also told the friend that the Registered Nurse would not visit if the Registered Nurse were not let into the patients home. At 06:31 PM the hospice Registered Nurse called the hospice On-Call Registered Nurse to inform her that the patient refused to go to the hospital and kicked everyone out of the house. The hospice Registered Nurse informed the hospice On-Call Registered Nurse that the Social Worker stated that “;she thinks the pt is not serious about overdosing.” At 07:12 PM the hospice On-Call Registered Nurse documented that she called the patient and that he refuses a nurse visit. Additionally, the patient stated to the hospice On-Call Registered Nurse “;what is going to happen? Am I going to die? Well, Im going to die anyway.” The patient further asked if the line was a recorded line. The hospice On-Call Registered Nurse informed him that the line was not recorded. In reply, the patient stated, “;I want to die on my own terms not at (the name of a hospital).” At 07:30 [no documentation as to whether the entry was AM or PM] the hospice On-Call Registered Nurse documented a call to the patients friend and informed the friend that the patient refused a nursing visit and “;seems very much like he just wants to be left alone and sleep.” Additionally, the patient “;made it clear that he understands he is dying and that he wants to die at home.” The patients friend stated that “;he doesnt think he will go back over tonight. He states that he hopes that this is the right decision...” During interview on 02/07/2024 at 09:15 AM, the Registered Nurse Care Coordinator stated she is not exactly sure what was meant by the statement “;the patient is in really bad shape” and she does not recall if these were her words or the patients friends. The Registered Nurse Care Coordinator stated the words “;even threatened to overdose” were the patients friends words. The Registered Nurse Care Coordinator further stated that the patients friend may not have been exactly saying overdose, and that the patients friend may have said “;taking too much medicine.” The Registered Nurse Care Coordinator stated she did not initiate a mental hygiene arrest because she was leaving that up to the hospices social worker. The Registered Nurse Care Coordinator stated she thought the meaning of the patients friends statement “;he states that he hopes that this is the right decision” just meant that the patients friend was concerned about the patient being alone because he was confused. The Registered Nurse Care Coordinator stated she did not conduct a formal suicide risk assessment. Lastly, the Registered Nurse Care Coordinator stated she now understands she should have done a suicide risk assessment. Review of the Charts/Clinical Notes with an effective date of 01/15/2024 and signed by the hospice Social Worker on 01/15/2024 at 03:40 PM revealed the Social Worker documented a series of entries. In the initial entry, entered at an unknown time, the hospice Social Worker stated she placed a telephone call to the patients friend to inform the friend of the “;situation” and to ask the patients friend if he could check-in on the patient today because of the patients “;disorientation.” The hospice Social Worker stated she reached a mailbox and left a message requesting a return phone call. In the second entry, entered at an unknown time, the hospice Social Worker stated she notified a hospice Registered Nurse, and the hospice Registered Nurse informed the Social Worker that the patient told the patients friend that “;he wishes to overdose on his pain medications. In the third entry, entered at 06:10 PM (approximately two and a half hours before the note was signed) the Social Worker stated she contacted the patients friend to inquire about the patients statement, but the Social Worker was unable to reach the patients friend. During interview on 02/06/2024 at 01:15 PM, the Social Work Manager stated she spoke with the patients friend and the friend felt like the patient would not act on his statements. The Social Work Manager stated that statements such as these would prompt an assessment of suicide risk, but a suicide risk assessment was not done. The Social Work Manager explained that the reason the times are off in her note is because she should have started a new entry on the 16th and not added to the entry she created on the 15th. The Social Work Manager stated that when she spoke with the patients friend regarding the patients suicide statements, the patients friend told her the patient would not act on the statements made and she trusted the friends opinion. Lastly, the Social Work Manger stated that she saw the patient the following day and she did not conduct a suicide risk assessment on this day either. Lastly, the Social Work Manager stated that in her visit template there is a suicide risk assessment that she could have selected and completed. Review of the Charts/Clinical Notes with an effective date of 01/16/2024 signed and dated by the hospice Registered Nurse on 01/16/2024 at 11:26 AM revealed the Registered Nurse stated she made a routine home visit to the patient to follow up on the patients disorientation. The Registered Nurse stated she was accompanied by the Social Worker. The Registered Nurse stated that the patient ambulated to the door to greet her, and the patient gait was slow and unsteady. The Registered Nurse stated that the patient was alert and oriented with intermittent confusion. The Registered Nurse stated that the patient stated he “;feels lightheaded and dizzy with ambulation.” Lastly, the Registered Nurse stated he feels that he can no longer “;look after himself.” Review of the Charts/Clinical Notes with an effective date of 01/16/2024 signed and dated by the hospice Social Worker on 01/16/2024 at 12:58 PM revealed the Social Worker stated she completed a co-visit with the Registered Nurse to “;check in with the patient.” The Social Worker stated that the patient was alert and oriented with forgetfulness. Additionally, the Social Worker stated the patient was a little light-headed and dizzy with ambulation. The Social Worker stated the patient does not think he can care for himself anymore. The Social Worker stated that due to the patients dizziness with ambulation she advised the patient to move any tables with sharp edges in case the patient has a fall. Lastly, the Social Worker stated the patient refused to move anything. Review of the Charts/Clinical Notes with an effective date of 01/16/2024 signed and dated by the hospice Social Worker on 01/16/2024 at 03:02 PM revealed the Social Worker documented a series of entries. In the initial entry, entered at an unknown time, revealed the Social Worker stated she was notified by the hospice On-Call Registered Nurse that the patients friends son went to check on the patient and found the patient on the floor. In the second entry, entered at 02:35 PM, the Social Worker stated that she spoke to the patients friend with confirmed that when his son went to check on the patient, he found the patient on the floor. The Social Worker stated that the patients friends son was able to get the patient off the floor and into a chair and that there were no visible injuries. Review of the Interdisciplinary Team Meeting Record dated 01/17/2024 revealed the Registered Nurse documented the following: 01/16/2024: Patient alert, oriented and pleasant on admission. Over the past few days, the patient has had increased confusion, agitation, and falls. Admitted to a comfort room at the hospital on 01/16/2024 until the patient can be transferred to the comfort home; 01/16/2024: Prior to being sent to the comfort home the patient was taking one (1) milliliter of Morphine approximately three (3) to four (4) times per day. With the increased confusion the patient was having difficulty managing all of his medications; 01/16/2024: Patient has no family in the area to provide care. Due to his rapid decline, the patient required immediate intervention. The patient was sent to the hospital for symptom management until a bed at the comfort home can be secured; and 01/16/2024: The patient is coping well with his terminal diagnosis and prognosis. The patient talks easily about his impending death. Review of the Interdisciplinary Team Meeting Record dated 01/17/2024 revealed the Social Worker documented the following: On 01/15/2024 the Social Worker and Registered Nurse visited the patient due to the patients sister reporting that the patient was “;incoherent.” The patient was alert, but not oriented times four; On 01/16/2024 the Social Worker completed another visit to the patient. The patient was oriented times four with confusion; and The patient is very accepting of his terminal diagnosis and pending death. The patient is willing to express his thoughts and feelings of his terminal condition and pending death. Review of the Interdisciplinary Team meeting Record dated 01/17/2024 lacked documented evidence the Registered Nurse and Social Worker communicated with the Interdisciplinary Team the safety concerns, improper medication usage, and statements of self-harm. During interview on 02/07/2024 at 04:15 PM the Registered Nurse Care Coordinator stated there is nothing regarding the patient statements of self-harm or safety concerns documented in the Interdisciplinary Team Meeting minutes. Patient #9 – This 90-year-old patient with the terminal diagnosis of unspecified diastolic (congestive) heart failure was admitted to the hospice on 01/04/2024. Review of the agency policy entitled “;Checking for and Removing an Impaction” last revised on 09/14/2023 revealed the following, “;Policy: Licensed nursing staff is able to check for and remove a fecal impaction per physicians order. 1) Verify the physicians order for the checking for or removal of an impaction...” Review of the Charts/Clinical Note effective 01/15/2024 revealed the Registered Nurse documented the patient has not had a bowel movement since 12/30/ (year not specified), the patients abdomen is soft and non-tender with bowel sounds in all four quadrants. The Registered Nurse documented that she performed a digital rectal exam and there was no stool in the patients rectal vault. Lastly, the Registered Nurse documented she administered a Dulcolax suppository, the patient passed a large amount of flatulence after the digital rectal exam, and the patient tolerated the procedure without difficulty. Review of the Charts/Clinical Note effective 01/16/2024 revealed the Registered Nurse documented a phone call was received from the patients daughter. The patients daughter informed the Registered Nurse that the patient had two bowel movements yesterday after receiving the suppository. The daughter also informed the Registered Nurse that the patient had some nausea and vomited a few times over night. The Registered Nurse documented that she informed the patients daughter that the nausea and vomiting may be the result of the “;suppository causing her gastrointestinal system to be irritated due to patient going so many days without a bowel movement.” Lastly, the Registered Nurse documented that she advised the patients daughter to administer the as needed Zofran to the patient and see if the nausea and vomiting improve. Review of the patient care record from 01/15/2024 to 02/06/2024 (date pf interview) lacked an order for the checking for or removal of an impaction as per policy. Review of the Interdisciplinary Team meeting Record dated 01/23/2024 revealed the Registered Nurse documented the following information under the Alteration in Gastrointestinal problem: patient has had two (2) Dulcolax suppositories within the past week, her bowels are now moving every day/every other day, and bowel sounds are present in all four quadrants. Review of the Interdisciplinary Team meeting Record dated 01/23/2024 lacked documented evidence the Registered Nurse communicated with the Interdisciplinary Team the need for a digital rectal exam and the patients complaint of nausea and vomiting. During interview on 02/06/2024 at 10:30 AM, the Senior Registered Nurse Care Coordinator stated she did not obtain an order for the digital exam per agency policy. Additionally, the Registered Nurse Care Coordinator stated that when she visited the patient on 01/22/2024 the nausea and vomiting had resolved, and the patient was moving her bowels regularly. The Registered Nurse Care Coordinator stated that because these problems had resolved there was no need to discuss them at the Interdisciplinary Meeting that occurred on 01/23/2024.”

“Based on review of clinical records and interviews with staff, the hospice failed to ensure in seven (7) of sixteen (16) patients (Patient #s: 4, 5, 6, 8, 9, 11, and 14) that care and services are provided in accordance with the Plan of Care. Specifically, medications, treatments and services are being provided based on identified needs and assessments but are not ordered on the plan of care. Failure to provide care in accordance with the patient’s established plan of care has the potential to result in inappropriate care, unmet patient needs and negative patient outcomes. Patient #5- This 63- year- old patient with a terminal diagnosis of malignant neoplasm of the pancreas, unspecified was admitted to the hospice on 10/16/2023. Review of the Charts/ Clinical Notes dated 01/09/2024 revealed the Registered Nurse contacted the patients primary doctor to request an order for Lidocaine gel/ cream for the patients coccyx pain. Review of the Physicians Orders/ Plan of Care dated 01/14/2024 reveal no order for Lidocaine gel/ cream. Review of the Team Care Plan dated 01/22/2024 lacked documented evidence of Lidocaine gel/ cream on the medication list. During interview on 02/08/2024 at 10:49 AM, the Registered Nurse Care Coordinator stated that the patients doctor ordered the Lidocaine on 01/09/2024, but the agency did not follow-up and send a supplemental order to the physician for signature and to retain in the record. Patient #6- This 82- year- old patient with a terminal diagnosis of End Stage Renal Disease was admitted to the hospice on 01/08/2024. Review of the Charts/Clinical Notes dated 01/12/2024 revealed the patient had a plugged ear and the patients physician ordered ear drops. Review of the clinical record from 01/12/2024 to 01/26/2024 lacked documented evidence that an order for ear drops was obtained. During interview on 02/07/2024 at 11:56 AM, the Senior Registered Nurse Care Coordinator stated there is no order for ear drops. Patient #8 – This 87-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung was admitted to the hospice on 01/17/2024 and expired on 01/20/2024. This patient was listed on the hospices active patient roster when the roster was requested by the surveyor on 01/22/2024. Review of the Charts/Clinical Notes effective 01/18/2024 revealed the Licensed Practical Nurse documented she inserted an 18 French Foley catheter with a 10 cubic centimeter balloon. Review of the Physicians Orders/Plan of Care dated 01/17/2024 lacked documented evidence of a Foley insertion order. During interview on 02/08/2024 at 02:19 PM, the Chief Nursing Officer stated that there are no orders for the Foley. Patient #14- This 89- year- old patient with terminal diagnosis of heart failure, unspecified was admitted to the hospice on 12/11/2023. Review of Charts/ Clinical Notes dated 12/21/2023 revealed the Registered Nurse placed a call to the patients primary care provider regarding patients possible urinary tract infection. The primary care provider informed the Registered Nurse that Augmentin was ordered. Review of the clinical record from 12/11/2023 through 01/29/2024 lacked a supplemental order for Augmentin. During interview on 02/06/202 at 11:00 AM, the Registered Nurse Care Coordinator stated that Augmentin should have been entered into the medications list, but it was not done. As a result, no order was generated. Patient #9 – This 90-year-old patient with the terminal diagnosis of unspecified diastolic (congestive) heart failure was admitted to the hospice on 01/04/2024. A. Review of the Oncall/Unscheduled Visit dated 01/08/2024 revealed the Registered Nurse documented she inserted a 16 French Foley catheter with a 10 cubic centimeter balloon. Review of the Physicians Orders/Plan of Care dated 01/04/2024 lacked documented evidence of a Foley insertion order. B. Review of the Oncall/Unscheduled Visit dated 01/11/2024 revealed the Registered Nurse documented the following: the patient has a stage 2 pressure ulcer to the right upper buttocks, measuring 0.6 centimeters long by 0.9 centimeters wide, the wound is draining a scant amount of serosanguinous drainage, there is no odor, cleansed the area, and applied a 3X3 Allevyn dressing. Review of the Physicians Orders/Plan of Care dated 01/04/2024 lacked documented evidence of a wound care order. C. Review of the Routine Visit dated 01/15/2024 revealed the Registered Nurse documented the following: the patient has a stage 2 pressure ulcer to the right upper buttocks, measuring 2.4 centimeters long by 2.1 centimeters wide, the wound is not healing, the wound is draining a moderate amount of serosanguinous/mucoid drainage, has a slight foul odor, cleansed the area with warm water, and applied a large Hydrocolloid dressing. Review of the Physicians Orders/Plan of Care dated 01/04/2024 lacked documented evidence of a wound care order. During interview on 02/05/2024 at 10:00 AM, the Senior Registered Nurse Care Coordinator stated it has not been her practice to obtain supplemental orders when activating standing orders. The Senior Registered Nurse Care Coordinator stated that she thought standing orders could be used whenever because they are a part of the standing order template. Patient #4 – This 72-year-old patient with the terminal diagnosis of malignant neoplasm of the colon, unspecified was admitted to the hospice on 01/23/2024. A. Review of the Charts/Clinical Notes effective 01/25/2024 revealed the Licensed Practical Nurse documented the patients sacral wound dressing was soiled with a scant amount of pale brown drainage. The Licensed Practical Nurse documented that she cleansed the sacrum with a bathing cloth, air dried, and applied a new 4X5 sacral Allevyn dressing. Review of the Physicians Orders/Plan of Care dated 01/23/2024 lacked documented evidence of a wound care order. During interview on 02/08/2024 at 02:30 PM, the Chief Nursing Officer stated that when a standing order is activated, a supplemental order should be generated and sent to the physician for signature. The Chief Nursing Officer stated she would look for the wound care order. As of exit no further information was provided to refute the findings. B. Review of the Charts/Clinical Notes effective 01/25/2024 revealed the Licensed Practical Nurse documented she inserted an 18 French Foley catheter with a 10 cubic centimeter balloon. Review of the Physicians Orders/Plan of Care dated 01/23/2024 lacked documented evidence of a Foley insertion order. During interview on 02/08/2024 at 02:30 PM, the Chief Nursing Officer stated that when a standing order is activated, a supplemental order should be generated and sent to the physician for signature. The Chief Nursing Officer stated she would look for the Foley order. As of exit no further information was provided to refute the findings. Patient #11 - This 51-year-old patient with the terminal diagnosis of malignant neoplasm of unspecified part of the unspecified bronchus or lung was admitted to the hospice on 12/29/2023 and expired on 01/06/2024. This patient was listed on the hospices active patient roster when the roster was requested by the surveyor on 01/22/2024. Review of the Charts/Clinical Notes effective 01/05/2024 revealed the Licensed Practical Nurse documented she inserted a 16 French Foley catheter with a 10 cubic centimeter balloon. Review of the Physicians Orders/Plan of Care dated 12/29/2023 lacked documented evidence of a Foley insertion order. During interview on 02/06/2024 at 03:00 PM, the Chief Nursing Officer stated there is no order to insert a Foley catheter.”

“Based on review of clinical records and interviews with staff, for four (4) of sixteen (16) clinical records (Patient #s: 7, 9, 12, and 14), the hospice failed to ensure ongoing sharing of information between all disciplines providing care. Failure to ensure the ongoing sharing of information has the potential for unmet patient needs. Patient #7- This 64-year-old patient with the terminal diagnosis malignant neoplasm of colon, unspecified was admitted to the hospice on 01/04/2024. A.) Review of the untitled document (Aide Time and Activity Sheet) dated 01/10/2024 revealed that the aide documented observations that needed to report to the Registered nurse as follows: the patient was eating less, was tired, weak, confused or drowsy, and needed more assistance with walking, transferring and toileting during the visit. Review of the clinical record from 01/10/2024 to 01/29/2024 lacked documented evidence that the aides observations were reported to the Registered Nurse. During interview on 02/06/2024 at 10:36 AM, the Senior Registered Nurse Care Coordinator stated that the aide called the Senior Registered Nurse Care Coordinator and reported the observations, and that the communication is documented in the agencys electronic system. Additionally, the Senior Registered Nurse Care Coordinator stated that the agency sent a Licensed Practical Nurse to the patients home to follow-up with the patient. The Senior Registered Nurse Care Coordinator stated that the documentation would be provided to the surveyors. As of exit, no further documentation was provided to refute the findings. Review of the clinical record from 01/10/2024 to 01/29/2024 lacked documentation of a visit to the patients home by the Licensed Practical Nurse, and documentation that the Licensed Practical Nurse was informed of the aides observations and need to conduct a visit to follow-up on the patients status. During interview on 02/06/2024 at 10:37 AM, the Senior Registered Nurse Care Coordinator stated that there is no documentation in the clinical record to show that the Licensed Practical Nurse was notified of the patients need for a visit, and no documentation of a Licensed Practical Nurse visit to the patient. B.) Review of the untitled document (Aide Time and Activity Sheet) dated 01/16/2024 revealed the aide documented that the patient has a small red area on the right elbow and coccyx. Additionally, the aide documented that the observations did not need to be reported to the Registered Nurse. Review of the clinical record from 01/16/2024 to 01/29/2024 revealed there is no documentation that the aide reported the changes in patients skin to the Registered Nurse. During interview on 02/06/2024 at 10:40 AM, the Senior Registered Nurse Care Coordinator stated that the changes in the patients skin were not reported to the Senior Registered Nurse Care Coordinator. The Senior Registered Nurse Care Coordinator also stated that if the aide had answered Yes, to the Visit Events question to notify the nurse, the change would have been seen and addressed by the Senior Registered Nurse Care Coordinator. Patient #12- This 84- year- old patient with a terminal diagnosis of malignant neoplasm of left renal pelvis was admitted to the hospice on 01/08/2024 and expired on 01/17/2024. This patient was listed on the hospices active patient roster when the roster was requested by the surveyor on 01/22/2024. Review of Charts/ Clinical Notes dated 01/15/2024 revealed the Registered Nurse documented a telephone call from a nurse at the comfort home where the patient resides regarding the patient being unable to swallow their quetiapine (Seroquel) and that the medication cannot be crushed. The nurse at the comfort home asked if the medication could be ordered in liquid form. The Registered Nurse documented that the physician suggested that the patient be given Ativan every four (4) hours as needed and if that doesnt help the patients symptoms after 24- 48 hours then the physician would order the requested liquid medication or try a different medication. Review of the clinical record from 01/15/2024 to 01/29/2024 revealed there is no documentation regarding whether the Ativan was effective and no documentation that the Registered Nurse communicated with the patients physician regarding the effectiveness of the Ativan or the need to prescribe liquid Quetiapine or another medication. During interview on 02/08/2024 at 01:22 PM, the Registered Nurse Care Coordinator stated that there was no documentation on the outcome of using Ativan versus Quetiapine. Patient #14- This 89- year- old patient with terminal diagnosis of heart failure, unspecified was admitted to the hospice on 12/11/2023. Review of Charts/ Clinical Notes dated 12/27/2023 revealed the Licensed Practical Nurse documented that the patients Ativan and Morphine were not observed in the patients home, and that the issue would be discussed with the Registered Nurse. Review of the clinical record from 12/27/2023 to 01/29/2024 revealed there was no documentation of any follow -up regarding the missing medications or an internal investigation initiated to determine whether there are concerns with medication administration or diversion. Review of the agency IDT (Interdisciplinary Team) Meeting Record dated 01/19/2024 revealed the patient denies pain and anxiety. Additionally, there is no documentation that the Interdisciplinary Team was notified about the missing medications. During interview on 02/08/2024 at 01:42 PM, The Chief Nursing Officer stated that there was no documented follow up regarding the missing medications.”

“Based on clinical record review and interview with agency staff, for one (1) of sixteen (16) records (Patient #19), the hospice failed to ensure there is an ongoing sharing of information and collaboration between the hospice and staff providing non-hospice care and services. The issues are: - Social Work failed to notify the patients primary care physician of the patients dysuria, disorientation, and confusion. - Registered Nurse failed to notify the patients primary care physician of the patients dysuria, disorientation, and confusion. Failure to ensure effective communication exists between all healthcare providers has the potential for the unmet patient needs and negative patient outcomes. Patient #19 – This 64-year-old patient with the terminal diagnosis of malignant neoplasm of the lung was admitted to the hospice on 01/09/2024, revoked the hospice benefit on 01/18/2024, and was discharged on 01/18/2024. A. Review of the Charts/Clinical Note effective 01/15/2024 revealed the Social Worker documented she received a phone call from the hospice Registered Nurse who had made a home visit to the patient and found the patient to be disoriented and confused. Additionally, the hospice Social Worker documented that the patient informed her on Friday that he had been having difficulty urinating for a couple of days. Lastly, the Social Worker documented that due to the patients disorientation a urinary tract infection is possible, and she notified the hospice Registered Nurse. Review of the clinical record from 01/15/2024 to 01/18/2024 (date of discharge) lacked documented evidence that the Social Worker notified the patient’s primary care physician of the patients dysuria, disorientation, and confusion. The hospice failed to ensure that ongoing sharing of information and collaboration between the hospice and staff providing non-hospice care and services. During interview on 02/06/2024 at 01:30 PM, the Social Work Manager stated when the patient reported having difficulty with urination, she asked the patient is he wanted her to tell nursing and the patient said “;no.” The Social Work Manager stated that she reminded the patient about on call services and that he could call someone if he needed anything. Additionally, the Social Work Manager stated she did not notify the patients primary care physician because the patient did not want anything done, and that the patient just wanted “;to see how the weekend goes.” Lastly, the Social Work Manager stated these conversations are not documented in the patients record. B. Review of the Charts/Clinical Note effective 01/15/2024 revealed the Social Worker documented she received a phone call from the hospice Registered Nurse who had made a home visit to the patient and found the patient to be disoriented and confused. Additionally, the hospice Social Worker documented that the patient informed her on Friday that he had been having difficulty urinating for a couple of days. Lastly, the Social Worker documented that due to the patients disorientation a urinary tract infection is possible, and she notified the hospice Registered Nurse. Review of the clinical record from 01/15/2024 to 01/18/2024 (date of discharge) lacked documented evidence that the Registered Nurse notified the patient’s primary care physician of the patients dysuria, disorientation, and confusion. The hospice failed to ensure that ongoing sharing of information and collaboration between the hospice and staff providing non-hospice care and services. During interview on 02/06/2024 at 11:30 AM, the Senior Registered Nurse Care Coordinator stated the first call was to the patient to see if she could get the patient to go to the hospital. The Senior Registered Nurse Care Coordinator stated this all happened at the end of the day and the patient refused to go to the hospital. Lastly, the Senior Registered Nurse Care Coordinator stated she handed the patient off to another nurse.”

“Based on review of clinical records, agency policy and procedure, observational home visits, and interview with agency staff for one (1) of four (4) patients observed during a home visit (Patient #2), the agency staff failed to follow accepted professional standards and agency policies and procedure for infection prevention. Failure to ensure compliance with acceptable professional standards and agency policies has the potential to place patients and staff at risk for exposure to infectious and/or communicable diseases which may result in negative staff and patient outcomes. Home Visit Patient #2 – This 68-year-old patient with the terminal diagnosis of malignant neoplasm of the colon, unspecified was admitted to the hospice on 01/03/2024. Review of the agencys policy entitled “;Nursing Bag Technique” last reviewed on 11/17/2022 revealed the following, “;4) Wash your hands in accordance with Policy and Procedure #502 – Hand Washing. 5) Remove all equipment to be used during the initial visit at one time and place on the work surface. 6) Note: Wash hands or use sanitizing gel if it is necessary to return to the bag...” The Registered Nurse failed follow the agencys bag technique policy as evidenced by the following: During an observational home visit conducted on 01/24/2024 at 10:30 AM, the surveyor observed the Registered Nurse obtain vital signs. While obtaining vital signs, the Registered Nurse was observed to wash her hands and then entered her nursing bag to retrieve a thermometer. After using the thermometer to obtain the patients temperature, the Registered Nurse placed the dirty thermometer on the work surface, and without removing her dirty gloves, the Registered Nurse returned to the inside of the nursing bag to retrieve a blood pressure cuff and stethoscope. During interview on 02/07/2023 at 03:27 PM, the Registered Nurse Care Coordinator stated the inside of the bag is clean and she should not have been going in and out of the bag with dirty hands. The Registered Nurse Care Coordinator stated the surveyors presence made her nervous which contributed to her incorrect bag technique.”

“Based on review of bereavement records, agency policy and procedure, and interviews with agency staff, it was determined in one (1) of three (3) bereavement records (Record #15) the bereavement program failed to follow the hospice policies and procedures. Failure to provide bereavement services has the potential to result in unmet needs for the bereaved. Review of the agencys policy entitled “;Bereavement Services” last reviewed on 09/28/2023 revealed, “;3. Recommendations for bereavement follow-up, including continued volunteer services, will be determined at the Interdisciplinary Team meeting following the patients death...A risk level will be determined by IDT as follows...c.) Low Risk Level-... Low risk level will be contacted within three weeks of death...” Bereavement Record #15 – Review of the bereavement record revealed the patient expired on 01/07/2023. Review of the Interdisciplinary Team Bereavement Form dated 01/11/2023 revealed the patients son was named as the bereaved and the bereaved risk level was identified as low. Review of the Charts/Clinical Note effective 02/08/2023 (twenty-eight days after the patient expired) revealed a Former Bereavement Coordinator stated he called and spoke with the bereaved, offered condolences, emotional support, and empathy; the bereaved declined all services. The agency failed to follow its policy in contacting a low risk bereaved within three weeks of expiration. In an email dated 01/12/2024 sent at 01:52 PM, the Social Work Manager stated “;Once the patient passes, us bereavement coordinators have three weeks to contact the bereaved and offer bereavement services. Since (the name of a former Bereavement Coordinator) waited a month to follow up with the bereaved, he did not meet the “;three week” requirement. Since he does not work here anymore, I cannot answer why he waited that long.””

“Based on review of the New York State Education Law Article 154, clinical records, and interviews with agency staff, for one (1) of eleven (11) patients (Patient #19) receiving Medical Social Work services, the Medical Social Worker failed to provide services within the legal scope of practice. Specifically, the Medical Social Worker failed to assess the patient’s suicide risk. Failure to comply with accepted standards of practice in furnishing professional services has the potential for negative patient outcomes. Patient #19 – This 64-year-old patient with the terminal diagnosis of malignant neoplasm of the lung was admitted to the hospice on 01/09/2024, revoked the hospice benefit on 01/18/2024, and was discharged on 01/18/2024. Review of the Charts/Clinical Notes with an effective date of 01/15/2024 and signed by the hospice On-Call Registered Nurse on 01/16/2024, revealed the hospice On-Call Registered Nurse documented a series of entries starting at 04:45 PM. At 04:45 PM the initial call was received by the hospice On-Call Registered Nurse in which the hospices answering service was informing the hospice On-Call Registered Nurse that the patients friend called the answering service to get in touch with a specific hospice nurse to get an update on the patient. At 05:03 PM, a second phone call was received from the hospices answering service informing the hospice that the patients friend had just arrived at the patients home and the patient was in “;really bad shape.” At 05:08 PM the hospice On-Call Registered Nurse contacted the patients friend. The friend stated that he wanted to know what was going on with the patient and whether the patient would be going to the hospital. During the conversation, the friend also inquired to know if the patient was going to the hospital by ambulance and if the ambulance was not going to pick him up someone was “;going to have to come out and help with the patient” The friend stated that the patient was confused and “;even threatened to overdose.” At 05:54 PM a Registered Nurse from the hospice called the hospice On-Call Registered Nurse to report that the patient was refusing to go to the hospital and that there was a comment about “;overdosing” and the hospice Registered Nurse was “;passing this information on to” the Social Worker. At 06:25 [no documentation as to whether the entry was AM or PM] the hospice On-Call Registered Nurse called the patients friend who stated that the ambulance was at the patients home, but the patient was refusing to go to the hospital, and the Emergency Medical Technicians were not going to take the patient to the hospital. The patients friend also reported that the patient told the patients friend to leave, and the patients friend was sitting in his car next to the ambulance. The hospice On-Call Registered Nurse asked the friend if the friend told the Emergency Medical Technicians about the patients threat to overdose. The patients friend told the hospice On-Call Registered Nurse that he did not because the patients friend thought it was a “;passing comment.” The hospice On-Call Registered Nurse documented that she spoke with the Emergency Medical Technician, who told the hospice On-Call Registered Nurse that the patient did not seem confused and is refusing transport, so they could not take him. The hospice On-Call Registered Nurse reported she informed the Emergency Medical Technician that the patient threatened to overdose himself and the hospice On-Call Registered Nurse recommended to the Emergency Medical Technician look into these statement more before leaving. The Emergency Medical Technician reported that the patient kicked the Emergency Medical Technicians out and slammed the door in their faces, and the Emergency Medical Technicians could not evaluate further. The hospice On-Call Registered Nurse documented that she spoke with the patients friend who asked for a hospice nurse to come out and assess the patient that evening. The hospice On-Call Registered Nurse told the friend that a Registered Nurse would call the patient in “;a little while after he [the patient] has had a chance to calm down a bit but if the pt [patient] is agreeable to her visiting tonight she will do so.” The hospice On-Call Registered Nurse also told the friend that the Registered Nurse would not visit if the Registered Nurse were not let into the patients home. At 06:31 PM the hospice Registered Nurse called the hospice On-Call Registered Nurse to inform her that the patient refused to go to the hospital and kicked everyone out of the house. The hospice Registered Nurse informed the hospice On-Call Registered Nurse that the Social Worker stated that “;she thinks the pt is not serious about overdosing.” At 07:12 PM the hospice On-Call Registered Nurse documented that she called the patient and that he refuses a nurse visit. Additionally, the patient stated to the hospice On-Call Registered Nurse “;what is going to happen? Am I going to die? Well, Im going to die anyway.” The patient further asked if the line was a recorded line. The hospice On-Call Registered Nurse informed him that the line was not recorded. In reply, the patient stated, “;I want to die on my own terms not at (the name of a hospital).” At 07:30 [no documentation as to whether the entry was AM or PM] the hospice On-Call Registered Nurse documented a call to the patients friend and informed the friend that the patient refused a nursing visit and “;seems very much like he just wants to be left alone and sleep.” Additionally, the patient “;made it clear that he understands he is dying and that he wants to die at home.” The patients friend stated that “;he doesnt think he will go back over tonight. He states that he hopes that this is the right decision...” During interview on 02/07/2024 at 09:15 AM, the Registered Nurse Care Coordinator stated she is not exactly sure what was meant by the statement “;the patient is in really bad shape” and she does not recall if these were her words or the patients friends. The Registered Nurse Care Coordinator stated the words “;even threatened to overdose” were the patients friends words. The Registered Nurse Care Coordinator further stated that the patients friend may not have been exactly saying overdose, and that the patients friend may have said “;taking too much medicine.” The Registered Nurse Care Coordinator stated she did not initiate a mental hygiene arrest because she was leaving that up to the hospices social worker. The Registered Nurse Care Coordinator stated she thought the meaning of the patients friends statement “;he states that he hopes that this is the right decision” just meant that the patients friend was concerned about the patient being alone because he was confused. The Registered Nurse Care Coordinator stated she did not conduct a formal suicide risk assessment. Lastly, the Registered Nurse Care Coordinator stated she now understands she should have done a suicide risk assessment. Review of the Charts/Clinical Notes with an effective date of 01/15/2024 and signed by the hospice Social Worker on 01/15/2024 at 03:40 PM revealed the Social Worker documented a series of entries. In the initial entry, entered at an unknown time, the hospice Social Worker stated she placed a telephone call to the patients friend to inform the friend of the “;situation” and to ask the patients friend if he could check-in on the patient today because of the patients “;disorientation.” The hospice Social Worker stated she reached a mailbox and left a message requesting a return phone call. In the second entry, entered at an unknown time, the hospice Social Worker stated she notified a hospice Registered Nurse, and the hospice Registered Nurse informed the Social Worker that the patient told the patients friend that “;he wishes to overdose on his pain medications. In the third entry, entered at 06:10 PM (approximately two and a half hours before the note was signed) the Social Worker stated she contacted the patients friend to inquire about the patients statement, but the Social Worker was unable to reach the patients friend. The Medical Social Worker failed to assess the patient’s suicide risk. During interview on 02/06/2024 at 01:15 PM, the Social Work Manager stated she spoke with the patients friend and the friend felt like the patient would not act on his statements. The Social Work Manager stated that statements such as these would prompt an assessment of suicide risk, but a suicide risk assessment was not done. The Social Work Manager explained that the reason the times are off in her note is because she should have started a new entry on the 16th and not added to the entry she created on the 15th. The Social Work Manager stated that when she spoke with the patients friend regarding the patients suicide statements, the patients friend told her the patient would not act on the statements made and she trusted the friends opinion. Lastly, the Social Work Manger stated that she saw the patient the following day and she did not conduct a suicide risk assessment on this day either. Lastly, the Social Work Manager stated that in her visit template there is a suicide risk assessment that she could have selected and completed.”

“Based on clinical record review, Medicare Benefit Policy Manual issued 11/30/2023, and staff interview, ten (10) of sixteen (16) clinical records (Patient #s: 2, 3, 5, 8, 9, 10, 11, 14, 18, and 19) lack documented evidence of the clinical information necessary for certification of the terminal illness. Failure to ensure the information used to establish the patient’s eligibility for hospice services and certify the terminal illness is in the clinical record has the potential for ineligible persons to be admitted to hospice services. Patient #3- This 76-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified part of the right bronchus or lung was admitted to the hospice on 01/09/2024. Review of the Certification Statement for the first 90-day period signed and dated by the hospices Medical Director on 01/17/2024 revealed the hospices Medical Director documented that the patient has stage four (4) lung cancer, is declining and opting for comfort care and is appropriate for hospice. There is a lack of documented evidence of specific clinical findings and other documentation supporting a life expectancy of six months or less. Patient #5- This 63- year- old patient with a terminal diagnosis of malignant neoplasm of the pancreas, unspecified was admitted to the hospice on 10/16/2023. Review of the Certification Statement for the first 90-day period signed and dated by the hospices Medical Director on 12/04/2023 revealed the hospices Medical Director documented that the patient has pancreatic cancer, is declining and opting for comfort care and is appropriate for hospice. There is a lack of documented evidence of specific clinical findings and other documentation supporting a life expectancy of six months or less. Patient #8 – This 87-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung was admitted to the hospice on 01/17/2024 and expired on 01/20/2024. This patient was listed on the hospices active patient roster when the roster was requested by the surveyor on 01/22/2024. On 01/22/2024 at 11:00 AM the surveyor requested an active patient roster. Review of the active patient roster provided on 01/22/2024 at 11:45 AM, listed Patient #8 an active patient. During interview on 02/09/2024 at 03:08 PM, the Chief Nursing Officer stated that the patient passed on 01/20/2024 which was over the weekend, so he was not removed by Monday 01/22/2024 when surveyors requested the record to review. Review of the Certification Statement for the first 90-day period signed and dated by the hospices Medical Director on 01/23/2024 revealed the hospices Medical Director documented that the patient has lung cancer, is declining and opting for comfort care and is appropriate for hospice. There is a lack of documented evidence of specific clinical findings and other documentation supporting a life expectancy of six months or less. Patient #10 – This 76-year-old patient with a terminal diagnosis of malignant neoplasm of pancreas unspecified was admitted to the hospice on 12/20/2023. Review of the Certification Statement for the first 90-day period signed and dated by the hospices Medical Director on 12/27/2023 revealed the hospices Medical Director documented that the patient has pancreatic cancer, is declining and opting for comfort care and is appropriate for hospice. There is a lack of documented evidence of specific clinical findings and other documentation supporting a life expectancy of six months or less. During interview on 02/07/2023 at 02:17 PM, the Chief Executive Officer stated the hospices medical director has been in practice for thirty years. The Chief Executive Officer stated that to her knowledge, this issue has never been brought up before. Patient #14- This 89- year- old patient with terminal diagnosis of heart failure, unspecified was admitted to the hospice on 12/11/2023. Review of the Certification Statement for the first 90-day period signed and dated by the hospices Medical Director on 12/15/2023 revealed the hospices Medical Director documented that the patient has End-stage heart failure and is hospice appropriate. There is a lack of documented evidence of specific clinical findings and other documentation supporting a life expectancy of six months or less. During interview on 02/06/2023 at 10:42 AM, the Chief Executive Officer stated Hospice appropriate is not a narrative. Review of the Medicare Benefit Policy Manual issues 11/30/2023 revealed, “;A complete written certification must include... 2. specific clinical findings and other documentation supporting a life expectancy of 6 months or less...” Patient #2 – This 68-year-old patient with the terminal diagnosis of malignant neoplasm of the colon, unspecified was admitted to the hospice on 01/03/2024. Review of the Certification Statement for the first 90-day period signed and dated by the hospices Medical Director on 01/23/2024 revealed the hospices Medical Director documented that the patient has stage colon cancer, is declining, is opting for comfort care, and is appropriate for hospice. There is a lack of documented evidence of specific clinical findings and other documentation supporting a life expectancy of six months or less. Patient #9 – This 90-year-old patient with the terminal diagnosis of unspecified diastolic (congestive) heart failure was admitted to the hospice on 01/04/2024. Review of the Certification Statement for the first 90-day period signed and dated by the hospices Medical Director on 01/23/2024 revealed the hospices Medical Director documented that the patient has end stage heart disease, has failed treatment, is declining, is opting for hospice care, and is appropriate for hospice. There is a lack of documented evidence of specific clinical findings and other documentation supporting a life expectancy of six months or less. Patient #11 - This 51-year-old patient with the terminal diagnosis of malignant neoplasm of unspecified part of the unspecified bronchus or lung was admitted to the hospice on 12/29/2023 and expired on 01/06/2024. This patient was listed on the hospices active patient roster when the roster was requested by the surveyor on 01/22/2024. Review of the Certification Statement for the first 90-day period signed and dated by the hospices Medical Director on 01/03/2024 revealed the hospices Medical Director documented that the patient has stage 4 lung cancer, has failed treatment, is declining, is opting for comfort care, and is appropriate for hospice. There is a lack of documented evidence of specific clinical findings and other documentation supporting a life expectancy of six months or less. Patient #18 – This 77-year-old patient with the terminal diagnosis of Parkinsons disease was admitted to the hospice on 01/15/2024, revoked the hospice benefit on 01/17/2024, and was discharged on 01/17/2024. Review of the Certification Statement for the first 90-day period signed and dated by the hospices Medical Director on 01/17/2024 revealed the hospices Medical Director documented that the patient has end stage Parkinsons disease, increasing confusion, poor intake, has failed treatment, is opting for comfort care, and is appropriate for hospice. There is a lack of documented evidence of specific clinical findings and other documentation supporting a life expectancy of six months or less. Patient #19 – This 64-year-old patient with the terminal diagnosis of malignant neoplasm of the lung was admitted to the hospice on 01/09/2024, revoked the hospice benefit on 01/18/2024, and was discharged on 01/18/2024. Review of the Certification Statement for the first 90-day period signed and dated by the hospices Medical Director on 01/17/2024 revealed the hospices Medical Director documented that the patient has stage 4 lung cancer, is declining, is opting for comfort care, and is appropriate for hospice. There is a lack of documented evidence of specific clinical findings and other documentation supporting a life expectancy of six months or less. During interview on 02/07/2023 at 02:17 PM, the Chief Executive Officer stated the hospices medical director has been in practice for thirty years. The Chief Executive Officer stated that to her knowledge, this issue has never been brought up before.”

“Based on clinical record review, agency policy and procedure, and interview with agency staff, for twelve (12) of sixteen (16) patient records (Patient #s: 1, 2, 3, 4, 5, 6, 7, 9, 11, 13, 14, and 18), the hospice failed to ensure the record was complete and contained all pertinent information related to the care and delivery of service to the patient. Failure to ensure clinical records are complete and contain all pertinent information related to patient care and services has the potential to result in inadequate and inappropriate care. Issues are: Documentation of the agency contact number on the Benefit Election Form. Documentation regarding patient assessment and communication was not complete and current. Documentation regarding Colace dosage is inconsistent. Documentation regarding Midodrine dosage is inconsistent. Documentation regarding medication start dates is inconsistent. Documentation regarding Home Health Aide reportable observations to the Registered Nurse is inconsistent. Documentation regarding Venous Access Device is inconsistent. Documentation regarding patients Diabetic status is inconsistent. Documentation regarding implemented treatment interventions is inconsistent. Documentation regarding the patients nutritional supplements calorie count is inconsistent. Hospice referral forms are incomplete. Documentation regarding the patients appetite is inconsistent. Documentation regarding the date of the patients last bowel movement is inconsistent. Documentation regarding the patients venous access is inconsistent. Failure to ensure clinical records are complete and accurate has the potential for the hospice to act on inaccurate information and may place the patient’s health and welfare at risk. Patient #1- This 102-year-old patient with the terminal diagnosis malignant neoplasm of bladder, unspecified was admitted to the hospice on 09/12/2022. A.) Review of the Hospice Benefit Election Form dated 09/12/2022 revealed 3. ... I understand that I, and my family, are encouraged to participate in the development of this Plan of Care and that Hospice can be reached at (line was left Blank). The Hospice Benefit Election Form is incomplete. It is unclear if the patient/ family were provided the Hospice contact number. During interview on 02/08/2024 at 11:23 AM, the Former Registered Nurse Case Coordinator stated that the Hospice contact number is given to the patient/ family on the Election of Benefits and that this blank line should have the hospice number. B.) Review of the Prognostic Checklist dated 09/14/2022 revealed only page two (2) of the form was present in the clinical record. During interview on 02/08/2024 at 02:23 PM, the Chief Nursing Officer stated that page one (1) of the form was done, but they cannot find it, and this was identified as missing while providing the record for review to the surveyor. C.) Review of the Charts/ Clinical Notes dated 09/12/2022 revealed the Registered Nurse documented that the patient was ordered to take Colace 100 milligrams, by mouth, once daily. Review of the Physicians Orders/ Plan of Care dated 09/12/2022 revealed an order for Colace 100 milligrams, 1 capsule daily by mouth. Review of the Physicians Orders/ Plan of Care dated 01/05/2024 revealed an order for Colace by mouth capsule 100 milligrams 500 milligrams daily by mouth constipation and bowel regimen. Review of the Team Care Plan dated 01/23/2024 revealed Medications: Colace by mouth capsule 100 milligrams 500 milligrams daily by mouth constipation and bowel regimen. During interview on 2/08/2024 at 11:35 AM, the Former Registered Nurse Care Coordinator stated that the patient was ordered to continue Colace 100 milligrams daily by mouth at admission, that the order has not changed, and they do not know why it changed. Patient #5- This 63- year- old patient with a terminal diagnosis of malignant neoplasm of the pancreas, unspecified was admitted to the hospice on 10/16/2023. A.) Review of the Initial Visit dated 10/16/2023 revealed the following: Access/ Infusion Sites: Check to document: Site 1 Midline Line inserted: Peripherally Inserted Central Catheter Insertion Intravenous Education: Not Applicable Comments: Patient wishes to have Peripherally Inserted Central Catheter line flushed Review of the Charts/ Clinical Notes dated 10/16/2023 revealed the Registered Nurse documented that they provided education on fall precaution and mediport care as patient wishes to maintain patency at this time. Review of the Physicians Orders/ Plan of Care lacked documented evidence of orders for patients venous access device. Review of the Team Care Plan dated 01/22/2024 revealed the following: Durable Medical Equipment/ Treatment Orders: Interventions: 10/16/2023: Venous access device- routine flushing. Registered Nurse/ Medical Doctor to cleanse venous access devise access site with betadine/ alcohol, flush with 20- 22-gauge ¾- 1” Huber needle using sterile technique. Flush mediport with five (5) milliliters Heparin flush (100 units/ milliliter) every monthly and as needed to maintain patency. Cover access site with occlusion dressing using sterile technique. The documentation in the visit is inconsistent with the Team Care Plan. It is unclear if the patient has a mediport or a peripherally inserted central catheter. During interview on 02/08/2024 at 10:01 AM, the Registered Nurse Care Coordinator stated that the patient has a mediport not a peripherally inserted central catheter, they made a mistake. B.) Review of the Charts/ Clinical Notes dated 10/26/2023 the Registered Nurse documented that they reconciled medications in the home with the medication list: Patient to continue per the Primary Care Provider: Gabapentin 300 milligrams by at bedtime, Midodrine Hydrochloride 5 milligrams by mouth twice daily, and Midodrine Hydrochloride 15 milligrams by mouth at bedtime. Review of the Physicians Orders/ Plan of Care dated 10/16/2023 revealed Medications: Midodrine Hydrochloride by mouth tablet 5 milligrams 5 milligrams twice daily by mouth hypertension, Midodrine Hydrochloride by mouth tablet 10 milligrams 10 milligrams at bedtime by mouth. Review of Medication List for Patient as of 10/16/2023 revealed the following: Midodrine Hydrochloride by mouth tablet 5 milligrams, 5 milligrams twice daily by mouth, Start Date: 10/16/2023, End date 01/27/2024. Midodrine Hydrochloride by mouth tablet 10 milligrams, 10 milligrams at bedtime by mouth, Start Date: 10/16/2023, End Date: 01/27/2024. Midodrine Hydrochloride by mouth, tablet 5 milligrams, 15 milligrams at bedtime by mouth, Start Date: 10/16/2023, End Date: 01/27/2024. Review of the Physicians Orders/ Plan of Care dated 01/14/2024 revealed Medications: Midodrine Hydrochloride by mouth tablet 5 milligrams 5 milligrams twice daily by mouth hypertension, Midodrine Hydrochloride by mouth tablet 5 milligrams 15 milligrams at bedtime by mouth. Review of the Team Care Plan dated 01/22/2024 revealed Medications: Midodrine Hydrochloride by mouth tablet 5 milligrams 5 milligrams twice daily by mouth hypertension, Midodrine Hydrochloride by mouth tablet 5 milligrams 15 milligrams at bedtime by mouth. The documented medication lists are inconsistent. It is unclear what Midodrine dose the patient is ordered. During interview 02/08/2024 at 10:05 AM, the Registered Nurse Care Coordinator stated that those are the medications they took looking at the bottles, that Midodrine 5 milligrams and Midodrine 15 milligrams was on the bottles, and they dont know why its like that on the care plan. The Registered Nurse then stated that the medication profile lists Midodrine 5 milligrams twice daily and Midodrine 10 milligrams at bedtime on 10/16/2023 that was discontinued and changed to Midodrine 5 milligrams twice daily and Midodrine 15 milligrams at bedtime was continued and they would print and send the medication profile and orders. As of exit, no further documentation was provided the refute the findings. Patient #6- This 82- year- old patient with a terminal diagnosis of End Stage Renal Disease was admitted to the hospice on 01/08/2024. A.) Review of the Chart/ Clinical Notes dated 01/22/2024 revealed the Registered Nurse documented the aide reporting a scratch on the patients back and that the patients said they have been itching like crazy. Review of untitled document (Aide Time and Activity Sheet) dated 01/22/2024 revealed Visit Events: Would you like to report observations to the Registered Nurse/ Supervisor: No. The Home Health Aides documentation is inconsistent with the Registered Nurses documentation. During interview on 02/07/2024 at 12:06 PM, the Senior Registered Nurse Care Coordinator stated that the aide should have marked Yes to the Visit Events questions and documented about the scratch even though they reported it in person. B.) Review of the Physicians Order/ Plan of Care dated 01/08/2024 revealed the patient is diagnosed with type 2 diabetes mellitus without complications. Review of the Interdisciplinary Team Meeting Record dated 01/11/2023 revealed the Registered Nurse documented under “;Alteration in Gastrointestinal/ Nutrition; Diabetes management that the patient is “;Not a Diabetic”. The documentation in the Physicians Orders/ Plan of Care and the Interdisciplinary Team Meeting Record are inconsistent. It is unclear if the patient does or does not have diabetes. During interview on 02/07/224 at 11:46 AM, the Senior Registered Nurse Care Coordinator stated that the date of the Interdisciplinary Team Meeting was 01/11/2024 and that they missed that step on the Interdisciplinary Team Meeting Record Sheet by mistake, the patient is diabetic. Patient #7- This 64-year-old patient with the terminal diagnosis malignant neoplasm of colon, unspecified was admitted to the hospice on 01/04/2024. The Registered Nurse failed to ensure all clinical notes are complete and current as evidenced by the following: Review of Hospice policy titled General Documentation Guidelines Policy number 202 last reviewed 07/27/2023, revealed “;...11.) Required documentation is completed within seventy-two (72) hours of service.” A.) Review of the Charts/ Clinical Note effective date 01/04/2024 revealed the Registered Nurse documented that a home visit was conducted on 01/04/2024 to admit the patient to hospice services. The note was electronically signed on 01/09/2024 at 10:14 AM (5 days after the patient was admitted). B.) Review of the Charts/ Clinical Note effective date 01/08/2024 revealed the Registered Nurse documented that she received a number of telephone calls regarding the patient. The initial call came from the patients sister who reported that the patient was dehydrated and asked if the patient should be brought to the Emergency Room for fluid rehydration. A second call was received from the patients physician reporting that the office contacted the patient to check in and the patient reported that he was in pain, but was told to drink more fluids. The Registered Nurse documented that she called the patient back to inquire about the patients pain. During the call, the patient requested a prescription for a Fentanyl patch. The Registered Nurse contact the physician to request an order for Fentanyl patch. The physician called the nurse and informed her that a prescription for the Fentanyl patch was sent to the pharmacy. The Registered Nurse then called the patients family and informed them that the Fentanyl was ordered, and she provided instruction as to its use/application. The note was electronically signed by the Registered Nurse on 01/22/2024 at 02:29 PM (14 days after the events took place). C.) Review of the Charts/ Clinical Note effective date 01/11/2024 revealed the Registered Nurse documented that she received a telephone call from the patients physician reporting that the office followed up again with the patient who stated that they did not have a Fentanyl patch on because they were waiting for the nurse to arrive. The Registered Nurse explained that the Licensed Practical Nurse visited the patient the previous date and noting was mentioned about the patch. The Registered Nurse then followed up with the patients daughter who stated that she would visit the patient after work and would apply the patch. The Registered Nurse encouraged the patients daughter to wear gloves when applying the patch. The note was electronically signed by the Registered Nurse on 01/22/2024 at 02:29 PM (11 days after the events took place). During interview on 02/06/2024 at 10:22 AM, the Registered Nurse Care Coordinator stated that they are aware that agency expectation for all documentation to be completed within 72 hours and that they were the only nurse completing admissions and got behind on their notes until 01/22/2024. Patient #3- This 76-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified part of the right bronchus or lung was admitted to the hospice on 01/09/2024. During a Home Visit on 01/24/2024 the Surveyor observed the Home Health Aide reporting to the Registered Nurse via telephone the patients changes in condition including increased weakness and anxiety, decreased oral intake and a new pressure wound reported by the patients family. Review of the Chart/ Clinical Notes dated 01/24/2024 revealed the Registered Nurse documented speaking to the aide who reported patient has increase in weakness noted, is experiencing increased anxiety, and is incoherent. Review of untitled document (Aide Time and Activity Sheet) dated 01/24/2024 revealed Visit Events: Would you like to report observations to the Registered Nurse/ Supervisor: No. The Home Health Aides documentation is inconsistent with the Surveyors observations and the Registered Nurses documentation. During interview on 02/08/ 2024 at 09:58 AM, the Registered Nurse Care Coordinator stated that the Home Health Aide should have documented Yes, to the Visit Event question and documented what he reported. Patient #14- This 89- year- old patient with terminal diagnosis of heart failure, unspecified was admitted to the hospice on 12/11/2023. Review of the Initial Visit dated 12/11/2023 revealed the following: Physical/ Nutrition: Nutritional Assessment: Appetite- fair, Dysphagia, Tube feedings: Kate Farms Peptide 1.5, Gravity Meal Pattern: 3 meals/ day, Meals prepared by: Caregiver/ family. Hydration: Good See Details: Not applicable. Review of the Physicians Orders/ Plan of Care dated 12/11/2023 revealed a lack of documented evidence of a diet or nutrition orders. Review of Supplemental Orders as of 12/11/2023 revealed the following: Gastric tube flush, Registered Nurse/ Licensed Practical Nurse/ Patient/ Primary Caregiver to give 3 milliliters of Kate Farms 1.4 calorie/ milliliter via percutaneous endoscopic gastrostomy bolus feed twice daily; flush with 50- 100 milliliters of water before and after all feeds and medication administration. Review of Supplemental Orders as of 12/13/2023 revealed the following: Kate Farms Peptide 1.5 by mouth liquid 1 units twice daily by mouth feed supplement. Review of the Team Care Plan dated 01/24/2024 revealed the following: Durable Medical Equipment/ Treatment Orders: Interventions: Gastric tube flush, Registered Nurse/ Licensed Practical Nurse/ Patient/ Primary Caregiver to give 3 milliliters of Kate Farms 1.4 calorie/ milliliter via percutaneous endoscopic gastrostomy bolus feed twice daily; flush with 50- 100 milliliters of water before and after all feeds and medication administration. The documentation in the visit, supplemental orders and the Team Care Plan are inconsistent. It is unclear what the calorie count of the patients nutritional supplement is. During interview on 2/06/2024 at 10:58 AM, the Registered Nurse Care Coordinator stated that they believe the calorie count was 1.5, they did not see the can, the family said it was 1.5 calories. So, 1.4 was an error. Patient #2 – This 68-year-old patient with the terminal diagnosis of malignant neoplasm of the colon, unspecified was admitted to the hospice on 01/03/2024. A. Review of the Hospice Referral form approved by the hospices Medical Director on 12/27/2023 revealed the following information was left blank: If the primary care physician agreement was sent to include the date it was sent and the initials of the person sending it, and - If the primary care physician agreement was returned to include the date it was returned and the initials of the person receiving it. The hospice failed to ensure clinical records are complete and accurate. During interview on 02/07/2024 at 03:15 PM, the Nursing Services Manager stated the referral form should be filled out in its entirety and this form is not. B. Review of the Routine Visit dated 01/10/2024 revealed the Registered Nurse documented the patients appetite is fair, the patient experiences early satiety, and the patient eats only bites two meals/day. Review of the Charts/Clinical Notes effective date of 01/10/2024 revealed the Registered Nurse documented that the patient reports her appetite as poor, and the patient eats one meal per day. The documentation in the visit is inconsistent with the documentation in the Charts/Clinical Notes. It is unclear how much and how often the patient is eating per day. During interview on 02/07/2024 at 03:15 PM, the Registered Nurse Care Coordinator stated she accidently clicked two meals a day. The Registered Nurse Care Coordinator stated she should have selected only bites per day because the patient was only eating bites of food each day. Patient #9 – This 90-year-old patient with the terminal diagnosis of unspecified diastolic (congestive) heart failure was admitted to the hospice on 01/04/2024. A. Review of the Hospice Referral form approved by the hospices Medical Director on 01/03/2024 revealed if the primary care physician agreement was returned to include the date it was returned and the initials of the person receiving it was left blank. The hospice failed to ensure clinical records are complete and accurate. During interview on 02/06/2024 at 09:15 AM, the Senior Registered Nurse Care Coordinator stated an agreement goes out to every doctor that is going to follow the patient. The Senior Registered Nurse Care Coordinator stated that when the agreement goes put and comes back, those dates should be written on the form. The Senior Registered Nurse Care Coordinator stated that possibly this one was forgotten. B. Review of the Initial Visit dated 01/04/2024 revealed the Registered Nurse documented that the patient has not had a bowel movement since last Saturday, 12/30/ (year not specified), five (5) days ago. Review of the Interdisciplinary Team Meeting Record dated 01/08/2024 revealed the Registered Nurse documented that as of 01/08/2024 the patient has not had a bowel movement in one (1) week. The documentation in the visit is inconsistent with the documentation in the Interdisciplinary Team Meeting Record. It is unclear how many days had passed since the patients las t bowel movement (seven or nine days). During interview on 02/06/2024 at 10:20 AM, the Senior Registered Nurse Care Coordinator stated, “;I acknowledge the inconsistencies in my documentation.” Patient #11 - This 51-year-old patient with the terminal diagnosis of malignant neoplasm of unspecified bronchus or lung was admitted to the hospice on 12/29/2023 and expired on 01/06/2024. This patient was listed on the hospices active patient roster when the roster was requested by the surveyor on 01/22/2024. Review of the Initial Visit dated 12/29/2023 revealed the Registered Nurse documented the patient does not have any access or infusion sites. Review of the Physicians Orders/Pan of Care dated 12/29/2023 revealed an order for the following: Venous access device - patient/patient care giver wishes not to maintain the site. Primary care physician agrees. Mediport not to be flushed per patient request. The documentation in the visit is inconsistent with the documentation in the Physicians Orders/Plan of Care. It is unclear if the patient does or does not have a venous access device. During interview on 02/07/2024 at 02:35 PM, the Registered Nurse Care Coordinator stated the patient has a port. Additionally, the Registered Nurse Care Coordinator stated that the orders are correct and the documentation in her assessment is not. Patient #13 – This 85-year-old patient with the terminal diagnosis of malignant neoplasm of the uterus, part unspecified was admitted to the hospice on 01/18/2024. Review of the Hospice Referral form approved by the hospices Interdisciplinary Team Physician on 01/10/2024 revealed the following information was left blank: - The patients code status; - If the patients primary care physician agrees to follow the hospice plan of care; - If the patients history and physical was requested; - If the primary care physician agreement was sent to include the date it was sent and the initials of the person sending it; and - If the primary care physician agreement was returned to include the date it was returned and the initials of the person receiving it. The hospice failed to ensure clinical records are complete and accurate. During interview on 02/07/2024 at 03:15 PM, the Nursing Services Manager stated the referral form should be filled out in its entirety and this form is not. Patient #4 – This 72-year-old patient with the terminal diagnosis of malignant neoplasm of the colon, unspecified was admitted to the hospice on 01/23/2024. Review of the unapproved and undated Hospice Referral form revealed the following information was left blank: The date the referral was approved; - The name of the physician approving the referral; - The patients code status; - If the patients primary care physician agrees to follow the hospice plan of care; - If the patients history and physical was requested; and - If the primary care physician agreement was returned to include the date it was returned and the initials of the person receiving it. The hospice failed to ensure clinical records are complete and accurate. During interview on 02/07/2024 at 03:15 PM, the Nursing Services Manager stated the referral form should be filled out in its entirety and this form is not. Patient #18 – This 77-year-old patient with the terminal diagnosis of Parkinsons disease was admitted to the hospice on 01/15/2024, revoked the hospice benefit on 01/17/2024, and was discharged on 01/17/2024. Review of the Hospice Referral form approved by the hospices Medical Director on 01/02/2024 revealed if the primary care physician agreement was returned to include the date it was returned and the initials of the person receiving it was left blank. The hospice failed to ensure clinical records are complete and accurate. During interview on 02/07/2024 at 03:15 PM, the Nursing Services Manager stated the referral form should be filled out in its entirety and this form is not.”

“Based on review of clinical records and interviews with staff, in three (3) of sixteen (16) patient records (Patient #s: 1, 9, and 10), the hospice failed to ensure the clinical record contains clear and concise evidence of the patient’s advanced directive choice. Failure to ensure patient records contain clear and concise advanced directives that are reflective of the patient’s wishes, places the patient at risk for not having his/her choices about medical treatment followed. Patient #1- This 102-year-old patient with the terminal diagnosis malignant neoplasm of bladder, unspecified was admitted to the hospice on 09/12/2022. Review of the Referral Form dated 09/08/2022 revealed the patient has a Health Care Proxy and a Do Not Resuscitate order. Review of the Charts/ Clinical Notes dated 09/12/2022 the Registered Nurse documented that a Do Not Resuscitate is in place and the patients Health Care Proxy is the patients daughter. Review of the patient care record from 09/12/2022 to 02/08/2024 (date of interview) lacked documented evidence of a Health Care Proxy. The agency failed to ensure there is clear and concise evidence of the patients advanced directives choices. During interview on 02/08/2024 at 11:40 AM, the Former Registered Nurse Case Coordinator stated that the patient had a Medical Order for Life Sustaining Treatment order, but they didnt state that. The Registered Nurse asked for copies but didnt it they got them. Patient #10 – This 76-year-old patient with a terminal diagnosis of malignant neoplasm of pancreas unspecified was admitted to the hospice on 12/20/2023. Review of the Referral Form dated 11/29/2023 revealed the patient has a Health Care Proxy and a Do Not Resuscitate order. Review of the Receipt of Informed Consent for Hospice Services dated 12/20/2023 revealed the form was signed by the patients spouse. Review of the Hospice Benefit Election Form dated 01/04/2024 revealed the form was signed by the patients spouse. Review of the patient care record from 12/20/2023 to 02/06/224 (date of interview) lacked documented evidence of a Health Care Proxy. The agency failed to ensure there is clear and concise evidence of the patients advanced directives choices. During interview on 02/06/2024 at 04:02 PM, the Senior Registered Nurse Care Coordinator stated that they were told there was a Health Care Proxy but it was not received from family. Patient #9 – This 90-year-old patient with the terminal diagnosis of unspecified diastolic (congestive) heart failure was admitted to the hospice on 01/04/2024. Review of the Referral Form dated 01/04/2024 revealed the patient has a Health Care Proxy. Review of the Receipt of Informed Consent for Hospice Services dated 01/04/2024 revealed the form was signed by an individual identified as the patients “;Health Care Proxy”. Review of the Hospice Benefit Election Form dated 01/04/2024 revealed the form was signed by an individual identified as the patients “;Health Care Proxy”. Review of the Initial Visit dated 01/04/2024 revealed the Registered Nurse documented the patients daughter is her Health Care Proxy and Power of Attorney. Review of the patient care record from 01/04/2024 to 02/06/2024 (date of interview) lacked documented evidence of a Health Care Proxy and/or a Power of Attorney. The agency failed to ensure there is clear and concise evidence of the patient’s advanced directive choices. During interview on 02/06/2024 at 09:30 AM, the Senior Registered Nurse Care Coordinator stated at admission the patient is asked for a copy of their advanced directive if they have it.”

“Based on clinical record review, agency policy and procedure, and staff interview the hospice failed to ensure a comprehensive discharge summary was prepared that contained all required components for two (2) of two (2) patients discharged to the community (Patient #s 18 and 19). Failure to prepare a comprehensive discharge summary places patients at risk for poor coordination of patient services and unmet patient needs upon discharge/transfer from the hospice. Review of the agency policy entitled “;Discharge of a Living Patient” last reviewed on 09/14/2023 revealed, “;2.) When the patient/primary caregiver initiates the discharge...c.) The Registered Nurse Care Coordinator notifies the patients attending physician of the patients desire to discharge from hospice services and receives an order to discharge...5.) The hospice discharge summary of a live patient must be forwarded to the patients attending physician and include: a.) a summary of the patients stay, including treatments, symptoms, and pain management; b. the patients current plan of care; c.) the patients latest physician orders; d.) any other documentation that will assist in post-discharge continuity of care, or that is requested by the attending physician or receiving facility...” Patient #18 – This 77-year-old patient with the terminal diagnosis of Parkinsons disease was admitted to the hospice on 01/15/2024, revoked the hospice benefit on 01/17/2024, and was discharged on 01/17/2024. The hospice failed to follow its policy as evidence by the following: - - Review of the patient record lacked documented evidence the hospice contacted the patients attending physician regarding the patients desire to discharge and obtained an order to discharge, and - - Review of the Agency Discharge Summary dated 01/17/2024 lacked documented evidence of a current plan of care, a summary of the patients stay including treatments, symptoms, and pain management, and the latest physician orders. Patient #19 – This 64-year-old patient with the terminal diagnosis of malignant neoplasm of the lung was admitted to the hospice on 01/09/2024, revoked the hospice benefit on 01/18/2024, and was discharged on 01/18/2024. The hospice failed to follow its policy as evidence by the following: - - Review of the patient record lacked documented evidence the hospice contacted the patients attending physician regarding the patients desire to discharge and obtained an order to discharge, and - - Review of the Agency Discharge Summary dated 01/18/2024 lacked documented evidence of a current plan of care, a summary of the patients stay including treatments, symptoms, and pain management, and the latest physician orders. During interview on 02/06/2024 at 12:00 PM, the Senior Registered Nurse Care Coordinator stated the hospice does not obtain an order for discharge and these components have not been included in the patients discharge summaries.”

“Based on clinical record review, agency policy and procedure, and staff interview the hospice failed to ensure in one (1) out of two (2) live discharge records of patients who were prescribed controlled drugs by the hospice (Patient #19), that the patient/caregiver are educated on the hospices policies and procedures for the safe use, management and disposal of controlled drugs. Failure to ensure hospice staff provide education to the patient/caregiver regarding the safe use, management and disposal of controlled drugs, and in a manner that the patient/caregiver understand, has the potential to result in the inappropriate use and disposal of controlled drugs jeopardizing the safety of the patient and/or the caregiver. Review of the agencys policy entitled “;Disposal of Controlled Medications” last reviewed 09/14/2023 revealed the following: “;I. A. When the patient no longer requires a particular controlled (or other) medication, the RN (Registered Nurse) Care Coordinator will remind the patient/primary caregiver of the reasons for destroying the medication and proper methods. These methods include removing unused, unneeded, or expired prescription medications from their original containers and placing the prescription drugs in impermeable, nondescript containers, such as empty cans or sealable plastic bags, followed by mixing medications in the container with an undesirable substance, such as coffee grounds, kitty litter or water with dish soap and then discarding these containers in the trash. B. The RN (Registered Nurse) Care Coordinator will document in the patients clinical record when and what instructions were given to the patient /primary caregiver for the disposal of the medications...In the event that the patient /primary caregiver refuses to dispose of the medication, the refusal to discard the medication will be documented in the patients clinical record... II. B. If during the visit, the destruction is refused by the responsible party, the RN (Registered Nurse), or their designee, informs the individual that federal law prohibits the transfer of any drug to any person other than the patient for whom it was prescribed. The refusal of the destruction must be documented by the RN (Registered Nurse); including the name of the person(s) who refused the destruction...” Patient #19 – This 64-year-old patient with the terminal diagnosis of malignant neoplasm of the lung was admitted to the hospice on 01/09/2024, revoked the hospice benefit on 01/18/2024, and was discharged on 01/18/2024. Review of the Oncall/Unscheduled Visit dated 01/17/2024 revealed the Registered Nurse documented she instructed the patient to place his comfort pack medications away in a cupboard so that he does not confuse them with his current medications. The Registered Nurse failed to discuss with the patient and/or their representative the safe use, management, and disposal of controlled drugs as per agency policy. During interview on 02/06/2024 at 11:50 AM, the Senior Registered Nurse Care Coordinator stated the reason she instructed the patient to place the controlled substances in his cupboard was because she was not sure how the patient would have received the instructions had she told him to dispose of the medications.”