Livingston County Hospice

“Based on clinical record review and interviews with staff, for nineteen (19) of nineteen (19) patients, the agency failed to ensure the patients receive information about the scope of services that the hospice will provide and specific limitations on those services. Failure to provide information about the scope of services that the hospice will provide and specific limitations on those services places all patients at risk for being unaware of potential financial liabilities. Patient #10- This 95-year-old patient with a terminal diagnosis of hypertensive heart and chronic kidney disease with heart failure was admitted to the hospice on 10/03/2024. Review of the clinical record lacks documented evidence of the following: - list of services that will be provided by the hospice - financial liability form delineating out of pocket costs to the patient Patient #15- This 95-year-old patient with a terminal diagnosis of unspecified lump in unspecified breast was admitted to the hospice on 11/29/2023. Review of the clinical record lacks documented evidence of the following: - list of services that will be provided by the hospice - financial liability form delineating out of pocket costs to the patient Patient #16- This 74-year-old patient with a terminal diagnosis of amyotrophic lateral sclerosis was admitted to the hospice on 05/22/2024. Review of the clinical record lacks documented evidence of the following: - list of services that will be provided by the hospice - financial liability form delineating out of pocket costs to the patient Patient #17- This 78-year-old patient with a terminal diagnosis of hypertensive heart and chronic kidney disease with heart failure was admitted to the hospice on 12/22/2023. Review of the clinical record lacks documented evidence of the following: - list of services that will be provided by the hospice - financial liability form delineating out of pocket costs to the patient The agency failed to ensure the patients receive information about the scope of services that the hospice will provide and specific limitations on those services as evidenced by the following: Patient #11 – This 77-year-old patient with a terminal diagnosis of malignant neoplasm of the colon was admitted to the hospice on 09/26/2024. Review of the clinical record lacks documented evidence of the following: - list of services that will be provided by the hospice; and - financial liability information delineating potential out of pocket costs to the patient. Patient #12 – This 75-year-old patient with a terminal diagnosis of chronic obstructive pulmonary disease was admitted to the hospice on 09/25/2024. Review of the clinical record lacks documented evidence of the following: - list of services that will be provided by the hospice; and - financial liability information delineating potential out of pocket costs to the patient. Patient #18 – This 66-year-old patient with a terminal diagnosis of malignant neoplasm of the endometrium was admitted to the hospice on 09/24/2024. Review of the clinical record lacks documented evidence of the following: - list of services that will be provided by the hospice; and - financial liability information delineating potential out of pocket costs to the patient. Patient #19 – This 86-year-old patient residing in a skilled nursing facility, with a terminal diagnosis of alzheimers disease, late onset was admitted to the hospice on 07/12/2024. Review of the clinical record lacks documented evidence of the following: - list of services that will be provided by the hospice; and - financial liability information delineating potential out of pocket costs to the patient. The agency failed to ensure the patients receive information about the scope of services that the hospice will provide and specific limitations on those services as evidenced by the following: Patient #1 – This 83-year-old patient with a terminal diagnosis of Parkinsons disease without dyskinesia was admitted to the hospice on 10/11/2024. Review of the clinical record lacks documented evidence of the following: - list of services that will be provided by the hospice - financial liability form delineating out of pocket costs to the patient Patient #2 -This 77-year-old patient with a terminal diagnosis of other sequela of cerebral infarction was admitted to the hospice on 11/01/2024. Review of the clinical record lacks documented evidence of the following: - list of services that will be provided by the hospice - financial liability form delineating out of pocket costs to the patient Patient #3 – This 93-year-old patient with a terminal diagnosis of Alzheimers disease was admitted to the hospice on 11/07/2024. Review of the clinical record lacks documented evidence of the following: - list of services that will be provided by the hospice - financial liability form delineating out of pocket costs to the patient Patient #4 – This 58-year-old patient with a terminal diagnosis of acute respiratory failure was admitted to the hospice on 11/06/2024. Review of the clinical record lacks documented evidence of the following: - list of services that will be provided by the hospice - financial liability form delineating out of pocket costs to the patient Patient #5 – This 74-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified part of left bronchus or lung was admitted to the hospice on 11/04/2024. Review of the clinical record lacks documented evidence of the following: - list of services that will be provided by the hospice - financial liability form delineating out of pocket costs to the patient Patient #6 – This 95-year-old patient with a terminal diagnosis of pathological fracture right femur sequela was admitted to the hospice on 11/01/2024. Review of the clinical record lacks documented evidence of the following: - list of services that will be provided by the hospice - financial liability form delineating out of pocket costs to the patient Patient #7 - This 98-year-old patient with a terminal diagnosis of congestive heart failure was admitted to the hospice on 10/25/2024. Review of the clinical record lacks documented evidence of the following: - list of services that will be provided by the hospice - financial liability form delineating out of pocket costs to the patient Patient #8 – This 34-year-old patient with a terminal diagnosis of malignant neoplasm of the rectum receiving inpatient hospice services at a local hospital was admitted to the hospice on 10/22/2024. Review of the clinical record lacks documented evidence of the following: - list of services that will be provided by the hospice - financial liability form delineating out of pocket costs to the patient Patient #9 – This 80-year-old patient with a terminal diagnosis of neurocognitive disorder with lewy bodies was admitted to the hospice on 10/21/2024. Review of the clinical record lacks documented evidence of the following: - list of services that will be provided by the hospice - financial liability form delineating out of pocket costs to the patient Patient #13 – This 61-year-old patient with a terminal diagnosis of malignant neoplasm of appendix was admitted to the hospice on 09/19/2024. Review of the clinical record lacks documented evidence of the following: - list of services that will be provided by the hospice - financial liability form delineating out of pocket costs to the patient Patient #14 – This 90-year-old patient with a terminal diagnosis of malignant neoplasm of prostate was admitted to the hospice on 08/14/2024. Review of the clinical record lacks documented evidence of the following: - list of services that will be provided by the hospice - financial liability form delineating out of pocket costs to the patient During interview on 11/18/2024 at 12:04 PM, the Director of Patient Services stated the agency does not have a financial liability form, but what the agency does is check the patients insurance and then call the patient if there is an out-of-pocket amount due. The Director of Patient Services stated the hospice documents the conversation in the record, but going forward the agency will implement a financial liability form to be signed by the patient/proxy. Additionally, the agency used to include the services provided on the Hospice Benefit Election Statement but have since been removed. There is nowhere in the admission process that outlines what services will be provided to the patient.”

“Based on review of clinical records and staff interview, one (1) of nineteen (19) patient records (Patient #15), lack evidence that the comprehensive assessment was completed by the hospice Interdisciplinary Group within five (5) days after the election of hospice care. Specifically, pastoral care services did not complete an assessment within five days of the patient’s election. Failure of the Interdisciplinary Group members to participate in completing the comprehensive assessment has the potential to place the patient/family at risk for the development of incomplete and/or inaccurate Plans of Care. The agency failed to ensure a comprehensive assessment is completed by the hospice Interdisciplinary Group within five (5) days after the election of hospice care as evidenced by the following: Patient #15- This 95-year-old patient with a terminal diagnosis of unspecified lump in unspecified breast was admitted to the hospice on 11/29/2023. Review of the Registered Nurse Start of Care Visit Note dated 11/29/2023 revealed the Registered Nurse documented that the patient requested to receive pastoral care services. Review of the Hospice Plan of Care for 11/29/2023 to 02/26/2024 revealed an order for the Chaplain to assess and evaluate.Review of the Chaplain Visit Note dated 12/07/2023 revealed the Chaplain completed the initial assessment on 12/07/2023, eight (8) days after the election of hospice care.During interview on 11/19/2024 at 02:29 PM, the Licensed Master Social Worker stated that there should have been a Chaplain visit within five (5) days of the referral. The Licensed Master Social Worker further stated that the Licensed Master Social Worker would check the Hospice Referral Spreadsheet for further documentation and will follow up with the Surveyor. As of exit, no further documentation was received to refute the finding.”

“Based on review of clinical records and interviews with agency staff, the hospice failed to ensure in eleven (11) of nineteen (19) clinical records (Patient #’s: 1, 2, 8, 10, 11, 13, 15, 16, 17, 18, and 19), the content of the comprehensive assessment is of sufficient scope to identify all the patient’s needs to promote the patient’s well-being and comfort throughout the dying process. Failure to ensure assessments are comprehensive has the potential for unmet patient needs and the likelihood of patient harm. The agency failed to ensure the content of the comprehensive assessment is of sufficient scope to identify all the patient’s needs to promote the patient’s well-being and comfort throughout the dying process as evidenced by: Patient #11 – This 77-year-old patient with a terminal diagnosis of malignant neoplasm of the colon was admitted to the hospice on 09/26/2024. Review of the Registered Nurse Start of Care Visit Note dated 09/26/2024 revealed the Registered Nurse documented “;vaccinations and screenings were completed by admitting clinician.” The assessment lacks documentation if the patient has received influenza and/or pneumonia vaccinations. During interview on 11/20/2024 at 12:30 PM, the Registered Nurse stated the identified question was answered incorrectly and was unaware of the need to track the patients influenza and pneumonia vaccination history. Patient #18 – This 66-year-old patient with a terminal diagnosis of malignant neoplasm of the endometrium was admitted to the hospice on 09/24/2024. Review of the Registered Nurse Start of Care Visit Note dated 09/24/2024 revealed the Registered Nurse documented being unable to obtain the patients vaccinations and screenings. Review of the clinical record lacks documentation regarding follow-up on obtaining the patients vaccination and screenings information. During interview on 11/19/2024 at 12:34 PM, the Supervising Public Health Nurse stated the Registered Nurse who completed the assessment no longer is employed by the hospice. The Supervising Public Health Nurse stated it is agency expectation for the staff to follow-up with the physician if the patient/ caregiver is unable to provide the identified information. Patient #19 – This 86-year-old patient residing in a skilled nursing facility, with a terminal diagnosis of alzheimers disease, late onset was admitted to the hospice on 07/12/2024. Review of the agency policy entitled “;Wound Management” dated 01/23/2024 revealed: “;The RN (Registered Nurse) will assess skin integrity during the initial assessment and as needed throughout the hospice admission. Any alterations in skin integrity will be initially documented in the emr (electronic medical record). Open wounds will be assessed weekly and measured for length, width, and depth.” A.) Review of the Registered Nurse Start of Care Visit Note dated 07/12/2024 revealed the Registered Nurse documented the patient has a decubitus/pressure ulcer of the left heel. The documentation lacks a wound assessment of the left heel. During interview on 11/19/1014 at 11:18 AM, the Registered Nurse stated being unable to recall why the left heel wound was not assessed, but stated a reason should have been documented for not completing the wound assessment. B.) Review of the Registered Nurse Start of Care Visit Note dated 07/12/2024 revealed the Registered Nurse documented the patient has diabetes mellitus, type 2 that is treated with insulin. Additionally, blood glucose monitoring occurs before meals and the patient is not able to self-test. The assessment lacks an obtained and/or recorded blood glucose reading. During interview on 11/19/2024 at 11:22 AM, the Registered Nurse stated the staff in the skilled nursing facility managed the patients diabetes monitoring and insulin administration. The Registered Nurse stated the patients blood glucose results should have been obtained from the skilled nursing facility staff but was not. Patient #16- This 74-year-old patient with a terminal diagnosis of amyotrophic lateral sclerosis was admitted to the hospice on 05/22/2024. A. Review of the Registered Nurse Start of Care Visit Note dated 05/22/2024 lacks documented evidence the Registered Nurse assessed the patients immunization status. During interview on 11/19/2024 at 10:10 AM, the Registered Nurse stated that vaccinations were discussed at the visit but were not documented. B. Review of the Registered Nurse Start of Care Visit Note dated 05/22/2024 revealed the Registered Nurse documented, “;Diet, Tube feedings, and Supplements: Tube feedings/ Supplements” The assessment lacks documentation of how the patient administers the tube feeding/ supplement, including use of a pump, or if given by gravity or bolus, the frequency of tube feedings/ supplements and the amount of each tube feeding/ supplement. During interview on 11/19/2024 at 10:16 AM, the Registered Nurse stated that the patient was administering the tube feeding by bolus, but the Registered Nurse did not observe the patient administering a feeding until another visit, because the patient was independent with the process. The Registered Nurse also stated that the tube feedings were discussed during the visit, but that discussion was not documented. C. Review of the Hospice Plan of Care for 05/22/2024 to 08/19/2024 revealed the following medication orders: Aspirin Low Dose 81 milligrams chewable tablet, chew one (1) tablet, once daily; B Complex Vitamin B capsule, take one capsule by gastrostomy tube, one (1) time daily; Centrum Silver therapeutic Multiple Vitamin with Minerals, take one (1) tablet orally, once daily; Feverall 650 milligrams rectal suppository, insert one (1) suppository rectally, every six (6) hours as needed for pain or fever; Fleet Bisacodyl ten (10) milligram rectal suppository, administer one (1) suppository rectally, once a day as needed for constipation; Furosemide forty (40) milligrams, take one (1) tablet orally, once daily; Haldol two (2) milligrams per milliliter oral concentrate, administer 0.25- 0.5 milliliters sublingually, every six (6) hours as needed for anxiety or nausea; Hyoscyamine 0.125 milligram tablet, take one (1) tablet sublingually, every six (6) hours as needed for secretions; Loratadine 10 milligrams capsule, take one (1) capsule orally, once a day; Lorazepam 2 milligrams per milliliter oral concentrate, administer 0.25- 0.5 milliliters orally, every four (4) hours as needed for anxiety; Magnesium Oxide 420 milligram tablet, take one (1) tablet orally, once daily; Morphine Sulfate 20 milligrams per milliliter concentrate, take 0.25-0.5 milliliters sublingually, every one (1) hour as needed for pain or shortness of breath; Prochlorperazine 10 milligrams tablet, take one (1) tablet orally, every six (6) hours as needed for nausea; May also be given rectally every six (6) hours as needed if unable to take orally or swallow the pill; Riluzole 50 milligrams tablet, take one (1) tablet orally, every twelve (12) hours; Ropinirole 1 milligram tablet, take one (1) tablet by gastrostomy tube, once daily; Senna S 50 milligrams- 8.6 milligrams tablet, take 1-2 tablets orally, once daily at bedtime as needed for constipation. Review of the Registered Nurse Start of Care Visit Note dated 05/22/2024 lacks documented evidence that the Registered Nurse assessed the patient/caregivers ability to safely administer medications both orally and via gastrostomy tube. During interview on 11/19/2024 at 10:19 AM, the Registered Nurse stated that the patient was taking all medications by mouth and would continue the oral route until the patient could not swallow the medications anymore, but this was not documented. Patient #10- This 95-year-old patient with a terminal diagnosis of hypertensive heart and chronic kidney disease with heart failure was admitted to the hospice on 10/03/2024. Review of the Registered Nurse Start of Care Visit Note dated 10/03/2024 lacks documented evidence the Registered Nurse assessed the patients immunization status. During interview on 11/20/2024 at 10:37 AM, the Registered Nurse stated that “;Completed by admitting clinician” was documented to indicate that the Registered Nurse had discussed vaccinations and screenings with the patient/ caregiver. The Registered Nurse further stated that they misunderstood the documentation and did not document the specific vaccines discussed, which included Influenza and Pneumonia vaccines. Patient #15- This 95-year-old patient with a terminal diagnosis of unspecified lump in unspecified breast was admitted to the hospice on 11/29/2023. Review of the Registered Nurse Start of Care Visit Note dated 11/29/2023 lacks documented evidence the Registered Nurse assessed the patients immunization status. During interview on 11/20/2024 at 01:58 PM, the Director of Patient Services stated that the patients pneumonia vaccine status was not addressed by the Registered Nurse at the start of care. The Director of Patient Services further stated that this has been identified and the agency will need to retrain staff on vaccination screenings. Patient #17- This 78-year-old patient with a terminal diagnosis of hypertensive heart and chronic kidney disease with heart failure was admitted to the hospice on 12/22/2023. Review of the Registered Nurse Start of Care Visit Note dated 12/22/2023 lacks documented evidence the Registered Nurse assessed the patients immunization status. During interview on 11/19/2024 at 11:02 AM, the Registered Nurse stated that the patients vaccination status was discussed but those vaccinations were not documented. The agency failed to ensure the content of the comprehensive assessment is of sufficient scope to identify all the patient’s needs to promote the patient’s well-being and comfort throughout the dying process as evidenced by: Patient #1 – This 83-year-old patient with a terminal diagnosis of Parkinsons disease without dyskinesia was admitted to the hospice on 10/11/2024. Review of the Registered Nurse Start of Care Visit Note dated 10/11/2024 lacks documented evidence the Registered Nurse assessed the patients immunization status. During interview on 11/19/2024 09:48 AM, the Registered Nurse stated the patient/family were unsure of the patients immunization status, the expectation is to follow-up with the physician and the Registered Nurse did not. Patient #2 -This 77-year-old patient with a terminal diagnosis of other sequela of cerebral infarction was admitted to the hospice on 11/01/2024. Review of the Registered Nurse Start of Care Visit Note dated 11/01/2024 lacks documented evidence the Registered Nurse obtained an arm circumference. During interview on 11/20/2024 at 12:07 PM, the Registered Nurse stated the expectation is that a baseline arm circumference is obtained at the start of care but was not for this patient. Patient #8 – This 34-year-old patient with a terminal diagnosis of malignant neoplasm of the rectum receiving inpatient hospice services at a local hospital was admitted to the hospice on 10/22/2024. Review of the Hospice Plan of Care for 10/22/2024 to 01/09/2025 revealed the following order: “;Skilled Nurse assess gastrointestinal status including bowel sounds and bowel elimination patterns.” Review of the Registered Nurse Start of Care Visit Note dated 10/22/2024 revealed the patient has an ostomy. The Registered Nurse documented the following gastrointestinal assessment: - ostomy assessment: not assessed - ostomy care/supplies: not assessed The Registered Nurse failed to assess bowel sounds, bowel elimination patterns, and the patients ostomy. During interview on 11/20/2024 at 09:42 AM, the Registered Nurse stated the hospital staff are responsible for the patients ostomy, and when the Hospice Registered Nurse tried to conduct a gastrointestinal assessment, the patient refused. The Registered Nurse stated they failed to document any information regarding the patients refusal or anything else pertaining to the assessment. Patient #13 – This 61-year-old patient with a terminal diagnosis of malignant neoplasm of appendix was admitted to the hospice on 09/19/2024. Review of the Registered Nurse Start of Care Visit Note dated 09/19/2024 lacks documented evidence the Registered Nurse assessed the patients immunization status. During interview on 11/20/2024 at 11:45 AM, the Registered Nurse stated she did not assess the immunization status.”

“Based on review of clinical records and interview with staff, for eleven (11) of nineteen (19) patients (Patient #’s: 2, 3, 4, 5, 8, 10, 14, 15, 16, 17, and 19), the hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review. Failure to complete accurate and comprehensive drug reviews has the potential for patients to experience drug interactions/side effects, and/or the Interdisciplinary Group to act on inaccurate information. Patient #16- This 74-year-old patient with a terminal diagnosis of amyotrophic lateral sclerosis was admitted to the hospice on 05/22/2024. A. Review of the referral to the agency dated 05/20/2024 revealed the following orders: - acetaminophen 325 milligrams - alprazolam 0.5 milligrams - azelastine 0.15% nasal spray - famotidine 8 milligram per milliliter suspension - naproxen 220 milligrams - miralax 17 grams Review of the Hospice Plan of Care for 05/22/2024 to 08/19/2024 lacks orders for the medications. Review of the clinical record lacks documented evidence the Registered Nurse communicated with the physician regarding the discrepancies. During interview on 11/19/2024 at 10:28 AM, the Registered Nurse stated that the patient reported not taking all the medications listed on the referral. The Registered Nurse reviewed the medications the patient was taking at the start of care and those medications were reconciled with the physician and added to the Plan of Care. The Registered Nurse also stated that it was documented that all medications were reconciled but did not list the specific medications. B. Review of the referral to the agency dated 05/20/2024 revealed the following order: aspirin 81 milligram enteric coated tablet, 1 (one) tablet orally, daily. Review of the Hospice Plan of Care for 05/22/2024 to 08/19/2024 lacks an order for the medication. Review of the clinical record lacks documented evidence the Registered Nurse communicated with the physician regarding the discrepancies. During interview on 11/19/2024 at 10:34 AM, the Registered Nurse stated that the patient was taking the chewable tablets, and that this was reviewed with the physician but not documented correctly. C. Review of the referral to the agency dated 05/20/2024 revealed the following order: furosemide 20 milligrams, 1 (one) tablet orally, every morning. Review of the Hospice Plan of Care for 05/22/2024 to 08/19/2024 lacks an order for the medication. Review of the clinical record lacks documented evidence the Registered Nurse communicated with the physician regarding the discrepancies. During interview on 11/19/2024 at 10:35 AM, the Registered Nurse stated that they went by what the patient/ family said the patient was taking and discussed it with the physician but did not document it. D. Review of the referral to the agency dated 05/20/2024 revealed the following order: magnesium oxide 400 milligrams,1 (one) tablet orally , every evening. Review of the Hospice Plan of Care for 05/22/2024 to 08/19/2024 lacks an order for the medication. Review of the clinical record lacks documented evidence the Registered Nurse communicated with the physician regarding the discrepancies. During interview on 11/19/2024 at 10:36 AM, the Registered Nurse stated that magnesium oxide 420 milligrams is what the patient had in the home and was taking. E. Review of the referral to the agency dated 05/20/2024 revealed the following order: multiple vitamins and minerals, 2 (two) capsules orally, twice daily. Review of the Hospice Plan of Care for 05/22/2024 to 08/19/2024 lacks an order for the medication. Review of the clinical record lacks documented evidence the Registered Nurse communicated with the physician regarding the discrepancies. During interview on 11/19/2024 at 10:37 AM, the Registered Nurse stated that the order on the Plan of Care is what the patient was taking, that this was discussed with the physician, but the Registered Nurse did not document what medications were reviewed. F. Review of the referral to the agency dated 05/20/2024 revealed the following order: ropinirole 1 milligram, 1 (one) tablet orally, every night. Review of the Hospice Plan of Care for 05/22/2024 to 08/19/2024 lacks an order for the medication. Review of the clinical record lacks documented evidence the Registered Nurse communicated with the physician regarding the discrepancies. During interview on 11/19/2024 at 10:44 AM, the Registered Nurse stated that the referral and the Plan of Care should match, that the Registered Nurse may have clicked on the wrong route on the Plan of Care order. G. Review of the referral to the agency dated 05/20/2024 revealed the following order: morphine 20 milligrams per milliliter concentrated solution, take 0.25 milliliters orally, twice daily as needed for pain. Review of the clinical record revealed a ComfortPak was ordered on 05/22/2024. Review of the “;Quick ComfortPak Guide” dated 03/19/2018 revealed the following: Symptom: Pain or Shortness of Breath ComfortPak Contents: Morphine Sulfate 20 milligrams per milliliter oral concentrate Directions: Take 0.25 milliliters by mouth or under the tongue every 1 (one) hour as needed for pain or shortness of breath. Review of the Hospice Plan of Care for 05/22/2024 to 08/19/2024 revealed the following order: morphine 20 milligrams per milliliter concentrate, take 0.25 milliliters to 0.5 milliliters sublingually, every 1 (one) hour as needed for pain or shortness of breath. Review of the clinical record lacks documented evidence the Registered Nurse communicated with the physician regarding the discrepancies. During interview on 11/19/2024 at 10:36 AM, the Registered Nurse stated that morphine is a comfort pack medication, and the order automatically fills in on the Plan of Care. At 10:37 AM the Director of Patient Services stated, “;The ComfortPak Guide needs to be updated, that the order on the Plan of Care is the standard comfort pack dose. H. Review of the referral to the agency dated 05/20/2024 lacks an order for Haldol. Review of the clinical record revealed a ComfortPak was ordered on 05/22/2024. Review of the “;Quick ComfortPak Guide” dated 03/19/2018 revealed the following: Symptom: Agitation or Restlessness ComfortPak Contents: Haloperidol 2 milligrams per milliliter oral concentrate Directions: Take 0.5 milliliters by mouth or under the tongue every 6 (six) hours as needed for agitation. Review of the Hospice Plan of Care for 05/22/2024 to 08/19/2024 revealed the following order: haldol 2 milligrams per milliliter oral concentrate, take 0.25 milliliters to 0.5 milliliters sublingually, every 6 (six) hours as needed for anxiety or nausea. Review of the clinical record lacks documented evidence the Registered Nurse communicated with the physician regarding the discrepancies. During interview on 11/19/2024 at 10:45 AM, the Registered Nurse stated that the Plan of Care should match the ComfortPak order, unless the physician changed it, but it is not documented. At 10:45 AM the Director of Patient Services stated that the ComfortPak Guide needs updates, the order on the Plan of Care is the standard dose. I. Review of the referral to the agency dated 05/20/2024 lacks an order for Lorazepam. Review of the clinical record revealed a ComfortPak was ordered on 05/22/2024. Review of the “;Quick ComfortPak Guide” dated 03/19/2018 revealed the following: Symptom: Anxiety ComfortPak Contents: Liquid Lorazepam 2 milligrams per milliliter Directions: Take 0.25 milliliters by mouth or under the tongue every 4 (four) hours as needed for anxiety. Review of the Hospice Plan of Care for 05/22/2024 to 08/19/2024 revealed the following order: lorazepam 2 milligrams per milliliter oral concentrate, take 0.25 milliliters to 0.5 milliliters orally, every 4 (four) hours as needed for anxiety. Review of the clinical record lacks documented evidence the Registered Nurse communicated with the physician regarding the discrepancies. During interview on 11/19/2024 at 10:46 AM, the Registered Nurse stated that in the standard order, the range comes up so the ComfortPak medication orders should be updated, and that is what the Registered Nurse told the patient when in the home. J. Review of the referral to the agency dated 05/20/2024 lacks an order for Senna S. Review of the Hospice Plan of Care for 05/22/2024 to 08/19/2024 the following order: senna s 50 milligrams- 8.6 milligrams, take 1 (one) to 2 (two) tablets orally, once daily at bedtime as needed for constipation and opioid use. Review of the clinical record lacks documented evidence the Registered Nurse communicated with the physician regarding the discrepancies. During interview on 11/19/2024 at 10:44 AM, the Registered Nurse stated that the hospice always orders senna s when the comfort pack is ordered. The Registered Nurse further stated that the order should have been documented, but the Registered Nurse forgot to do it. Patient #10- This 95-year-old patient with a terminal diagnosis of hypertensive heart and chronic kidney disease with heart failure was admitted to the hospice on 10/03/2024. A. Review of the referral to the agency dated 10/02/2024 revealed the following orders: - muscle rub, apply to neck and shoulders, twice daily as needed - miralax, 17 grams orally, once daily - oxycodone 5 milligrams, 0.5 tablet orally, every 6 (six) hours as needed Review of the Hospice Plan of Care for 10/03/2024 to 12/31/2024 lacks orders for the medications. During interview on 11/20/2024 at 10:49 am, the Registered Nurse stated that these medications were omitted from the Plan of Care by mistake. B. Review of the referral to the agency dated 10/02/2024 revealed the following order: acetaminophen 500 milligrams, 2 (two) tablets orally, every 8 (eight) hours. Review of the Hospice Plan of Care for 10/03/2024 to 12/31/2024 revealed an order for tylenol 500 milligrams, 2 (two) tablets orally, every 8 (eight) hours as needed for pain. Review of the clinical record lacks documented evidence the Registered Nurse communicated with the physician regarding the discrepancies. During interview on 11/20/2024 at 10:45 am, the Registered Nurse stated the acetaminophen was a scheduled medication and an error was made on the Plan of Care. C. Review of the referral to the agency dated 10/02/2024 revealed the following order: levothyroxine 75 micrograms, 1 (one) tablet orally, once daily at 04:00 PM. Review of the Hospice Plan of Care for 10/03/2024 to 12/31/2024 revealed an order for levothyroxine 75 micrograms, 1 (one) tablet orally, once daily, give in the morning. Review of the clinical record lacks documented evidence the Registered Nurse communicated with the physician regarding the discrepancies. During interview on 11/20/2024 at 10:45 am, the Registered Nurse stated that they did not see that the levothyroxine was ordered for 04:00 PM on the referral, that the Plan of Care should match the referral. D. Re view of the referral to the agency dated 10/02/2024 revealed the following order: prednisone 1 milligram, 2 (two) tablets orally, once daily. Review of the Hospice Plan of Care for 10/03/2024 to 12/31/2024 revealed an order for prednisone 1 milligram, 1 (one) tablet orally, twice daily. Review of the clinical record lacks documented evidence the Registered Nurse communicated with the physician regarding the discrepancies. During interview on 11/20/2024 at 10:48 AM, the Registered Nurse stated that this order was questioned at the start of care visit, but the discussion was not documented. The Registered Nurse also stated that this was possibly an error on the referral medication list, but no other follow up was done to correct it. E. Review of the referral to the agency dated 10/02/2024 revealed the following treatment order: skin prep wipes, 1 (one) wipe, to outer lobe of bilateral ears, every 12 (twelve) hours. Review of the Hospice Plan of Care for 10/03/2024 to 12/31/2024 lacks an order for skin prep wipes. Review of the clinical record lacks documented evidence the Registered Nurse communicated with the physician regarding the discrepancies. During interview on 11/20/2024 at 10:50 AM, the Registered Nurse stated that this order did not go on the Plan of Care because the patient was refusing this treatment, so the facility was not doing the treatment. The Registered Nurse further stated that the patients refusal should have been documented and a discontinue order should have been requested. Patient #15- This 95-year-old patient with a terminal diagnosis of unspecified lump in unspecified breast was admitted to the hospice on 11/29/2023. A. Review of the referral to the agency dated 11/27/2024 revealed the following order: lidocaine 4% patch, 1 (one) patch topically, every 24 (twenty-four) hours. Review of the Hospice Plan of Care for 11/29/2023 to 02/26/2024 lacks an order for this medication. Review of the clinical record lacks documented evidence the Registered Nurse communicated with the physician regarding the discrepancies. During interview on 11/20/2024 at 02:10 PM, the Director of Patient Services stated that there was no evidence of the lidocaine patch on the Plan of Care. B. Review of the referral to the agency dated 11/27/2023 revealed the following order: dextromethorphan- guaifenesin 10 milligrams-100 milligrams per 5 milliliters, 10 (ten) milliliters orally, every 4 (four) hours as needed for congestion or cough. Review of the Hospice Plan of Care for 11/29/2023 to 02/26/2024 revealed an order for dextromethorphan- guaifenesin 10 milligrams-100 milligrams per 10 milliliters, 10 (ten) milliliters orally, every 4 (four) hours as needed for cough. Review of the clinical record lacks documented evidence the Registered Nurse communicated with the physician regarding the discrepancies. During interview on 11/20/2024 at 02:11 PM, the Director of Patient Services stated that the dosage on the Plan of Care is incorrect, that the clinician must have made an error. C. Review of the referral to the agency dated 11/27/2023 revealed the following order: loperamide 2 milligrams, take 4 (four) milligrams orally, twice daily as needed for diarrhea. Review of the Hospice Plan of Care for 11/29/2023 to 02/26/2024 revealed an order for loperamide 2 milligrams, take 1 (one) capsule (2 milligrams) orally, twice daily as needed for diarrhea. Review of the clinical record lacks documented evidence the Registered Nurse communicated with the physician regarding the discrepancies. During interview on 11/20/2024 at 02:13 PM, the Director of Patient Services stated that there is no documentation in the record to show why the dosage should be different on the Plan of Care. D. Review of the referral to the agency dated 11/27/2023 revealed the following order: milk of magnesia 400 milligrams per 5 milliliters, take 30 (thirty) milliliters orally, daily as needed. Review of the Hospice Plan of Care for 11/29/2023 to 02/26/2024 revealed an order for milk of magnesia 24% oral concentrate, administer 5 (five) milliliters orally, daily as needed for constipation. Review of the clinical record lacks documented evidence the Registered Nurse communicated with the physician regarding the discrepancies. During interview on 11/20/2024 at 02:14 PM, the Director of Patient Services stated that the referral medication list and the Plan of Care order should match. Patient #17- This 78-year-old patient with a terminal diagnosis of hypertensive heart and chronic kidney disease with heart failure was admitted to the hospice on 12/22/2023. A. Review of the referral to the agency dated 12/22/2023 revealed the following order: chlorhexidine gluconate mouth/ throat solution 0.12%, 15 (fifteen) milliliters orally, three times daily for 10 (ten) days. Review of the Hospice Plan of Care for 12/22/2023 to 03/20/2024 revealed an order for chlorhexidine 0.12% mucous membrane liquid, 12 (twelve) milliliters orally, three times daily for 10 (ten) days. Review of the clinical record lacks documented evidence the Registered Nurse communicated with the physician regarding the discrepancies. During interviews on 11/19/2024 at 11:10 AM, the Registered Nurse stated that 12 (twelve) milliliters was documented in error, the order should be for 15 (fifteen) milliliters. B. Review of the referral to the agency dated 12/22/2023 revealed the following order: folic acid 1 milligram, 1 (one) tablet orally, daily. Review of the Hospice Plan of Care for 12/22/2023 to 03/20/2024 revealed an order for folic acid 0.4 milligrams, 1 (one) tablet orally, daily. Review of the clinical record lacks documented evidence the Registered Nurse communicated with the physician regarding the discrepancies. During interviews on 11/19/2024 at 11:11 AM, the Registered Nurse stated that this was another mistake, the dosage should be 1 (one) milligram. C. Review of the referral to the agency dated 12/22/2023 revealed the following order: Zofran 4 milligrams, 0.5 tablet orally, three times daily as needed, special instructions: 2 (two) milligrams orally, every 6 (six) hours three times daily as needed. Review of the Hospice Plan of Care for 12/22/2023 to 03/20/2024 revealed an order for ondansetron 4 milligrams, 0.5 tablet orally, every 6 (six) hours three times daily as needed for nausea. Review of the clinical record lacks documented evidence the Registered Nurse communicated with the physician regarding the discrepancies. During interviews on 11/19/2024 at 11:14 AM, the Registered Nurse stated that visit must have been on a bad day, this was another typographical error and should be ordered every 8 (eight) hours not every 6 (six) hours. The hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review as evidenced by the following: Patient #19 – This 86-year-old patient residing in a skilled nursing facility, with a terminal diagnosis of alzheimers disease, late onset was admitted to the hospice on 07/12/2024. A.) Review of the Medication Administration Record from the skilled nursing facility provided with the referral for hospice services dated 07/09/2024 revealed the following order: - milk of magnesia 400 milligrams per 5 milliliters, take 30 milliliters once a day as needed for constipation. Review of the Hospice Plan of Care for 07/12/2024 to 10/09/2024 revealed an order for milk of magnesia 1200 milligrams per 5 milliliters oral liquid; take 30 milliliters orally three (3) times a day as needed for constipation. Review of the clinical record lacks documentation the Registered Nurse communicated with the physician and/or the interdisciplinary group regarding the medication discrepancy. During interview on 11/19/2024 at 11:31 AM, the Registered Nurse stated the dose was mistakenly written as three times daily as needed, on the plan of care. B.) Review of the Medication Administration Record from the skilled nursing facility provided with the referral for hospice services dated 07/09/2024 revealed the following orders: - oxycodone 5 milligrams, one tablet oral given once a day prior to therapy; and - oxycodone 5 milligrams, one tablet oral, every four (4) hours as needed for pain. Review of the Hospice Plan of Care for 07/12/2024 to 10/09/2024 revealed an order for oxycodone 5 milligrams oral tablet; take one (1) tab oral every four (4) hours as needed for pain. The plan of care lacks an order for a scheduled oxycodone dose daily. Review of the clinical record lacks documentation the Registered Nurse communicated with the physician and/or the interdisciplinary group regarding the medication discrepancy. During interview on 11/19/2024 at 11:35 AM, the Registered Nurse stated an error was made as the patient should have been ordered a scheduled dose of oxycodone in addition to the as needed order. C.) Review of the Medication Administration Record from the skilled nursing facility provided with the referral for hospice services dated 07/09/2024 revealed the following order: - santyl 250 unit per gram ointment, apply light coating topically once a day to left heel wound and cover with dry sterile dressing. Review of the Hospice Plan of Care for 07/12/2024 to 10/09/2024 revealed an order for: - santyl 250 units per gram topical ointment; apply one (1) application topical once a day. The order lacks documentation of the location to apply the santyl ointment. During interview on 11/19/2024 at 11:32 AM, the Registered Nurse stated the santyl was to be applied to the patients left heel but was left off the plan of care in error. The hospice failed to ensure that nursing staff complete an accurate and comprehensive drug review as evidenced by the following: Patient #14 – This 90-year-old patient with a terminal diagnosis of malignant neoplasm of prostate was admitted to the hospice on 08/14/2024. A. Review of the Hospice Plan of Care for 08/14/2024 to 11/11/2024 revealed the following duplicate order: hyoscyamine 0.125 milligram tablet; take one tab sublingually every four hours as needed for secretions. During interview on 11/20/2024 at 09:45 AM, the Registered Nurse stated the duplicate order is an error. B. Review of the Hospice Plan of Care for 08/14/2024 to 11/11/2024 revealed the following orders: - lorazepam 0.5 milligram tablet; take 0.5 milligrams orally every six hours as needed for anxiety - lorazepam 2 milligrams/milliliters oral concentrate; administer 0.5 to 1 milligram orally every four hours as needed for anxiety During interview on 11/20/2024 at 09:47 AM, the Registered Nurse stated the patient should only have one order of lorazepam. C. Review of the referral to the agency dated 08/13/2024 revealed the following orders: - flomax 0.4 milligram capsule - protonix 40 milligram extended-release tablet - calcium- vitamin D- vitamin K chew Review of the Hospice Plan of Care for 08/14/2024 to 11/11/2024 lacks orders for the medications. Review of the clinical record lacks documented evidence the Registered Nurse communicated with the physician regarding the discrepancies. During interview on 11/20/2024 at 09:38 AM, the Registered Nurse stated there was a call do the physician, but the medications discussed were not specifically documented. Patient #2 -This 77-year-old patient with a terminal diagnosis of other sequela of cerebral infarction was admitted to the hospice on 11/01/2024. Review of the Hospice Plan of Care for 11/01/2024 to 01/29/2025 revealed the following orders: - acetaminophen 325 milligrams oral tablet; take two tabs oral three times a day for mild pain; not to exceed three grams from all sources in a 24 (twenty-four) hour period; - aspi-cor 81 milligrams oral delayed release tablet; take one tab orally once a day for heart Review of the Nursing and Rehabilitation Medication Administration Record dated 11/13/2024 lacks orders for the medications. Review of the clinical record lacks documented evidence the Registered Nurse communicated with the physician regarding the discrepancies. During interview on 11/20/2024 at 12:00 PM, the Registered Nurse stated the Plan of Care and Medication Administration Record should match and will clarify the orders. Patient #3 – This 93-year-old patient with a terminal diagnosis of Alzheimers disease was admitted to the hospice on 11/07/2024. Review of the referral to the agency dated 11/01/2024 revealed the following orders: - aspirin 81 milligram extended-release tablet - vitamin D 1000 unit capsule - clotrimazole 10 milligrams lozenge - flonase nasal spray - levothyroxine 112 microgram tablet - metoprolol succinate extended release 25 milligrams 24 (twenty-four) hour tablet - simvastatin 10 milligram tablet Review of the Hospice Plan of Care for 11/07/2024 to 02/04/2025 lacks orders for the medications. Review of the clinical record lacks documented evidence the Registered Nurse communicated with the physician regarding the discrepancies. During interview on 11/19/2024 at 12:14 PM, the Registered Nurse stated there was no communication with the physician regarding the discrepancies. Patient #4 – This 58-year-old patient with a terminal diagnosis of acute respiratory failure was admitted to the hospice on 11/06/2024. Review of the referral to the agency dated 10/23/2024 revealed the following orders: - senna tablet - valproic acid 500 milligrams - castor oil one application Review of the Hospice Plan of Care for 11/06/2024 to 02/03/2025 lacks orders for the medications. Review of the clinical record lacks documented evidence the Registered Nurse communicated with the physician regarding the discrepancies. During interview on 11/19/2024 at 03:18 PM, the Registered Nurse stated there was no communication with the physician regarding the discrepancies. Patient #5 – This 74-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified part of left bronchus or lung was admitted to the hospice on 11/04/2024. Review of the discharge summary dated 10/29/2024 revealed the following orders: - eliquis 5 milligram tablet - dexamethasone 2 milligram tablet - folic acid 1 milligram tablet - multivitamin tablet Review of the Hospice Plan of Care for 11/04/2024 to 02/01/2025 lacks orders for the medications. Review of the clinical record lacks documented evidence the Registered Nurse communicated with the physician regarding the discrepancies. During interview on 11/20/2024 at 11:44 AM, the Registered Nurse stated they dont recall speaking with the physician regarding the medications. Patient #8 – This 34-year-old patient with a terminal diagnosis of malignant neoplasm of the rectum receiving inpatient hospice services at a local hospital was admitted to the hospice on 10/22/2024. Review of the Hospice Plan of Care for 10/22/2024 to 01/09/2025 revealed the following orders: - morphine 1 milligram/milliliter sodium chloride 9% (nine percent) intravenous solution, inject ten milligrams intravenous every hour for pain, shortness of breath; - morphine 1 milligram/milliliter preservative-free intravenous solution, inject twelve milligrams intravenous every hour for pain, shortness of breath; may be increased to 20 gram/hour for uncontrolled pain; - morphine 1 milligram/milliliter sodium chloride intravenous solution, inject six milligrams intravenous every two hours for pain, shortness of breath During interview on 11/20/2024 at 09:38 AM, the Director of Patient Services stated the patient does not use all three orders of morphine this is an error.”

“Based on a review of clinical records and staff interview, seven (7) of nineteen (19) clinical records (Patient #’s: 1, 11, 12, 15, 16, 18, and 19) lacks evidence that the patient’s comprehensive assessments included changes that had occurred since the initial assessment or were updated every fifteen (15) days or that the hospice nurses are communicating changes in the patient’s condition or treatment to the Interdisciplinary Group. Failure to ensure that comprehensive assessments are updated and reflect the patient’s status has the potential for unmet patient needs. The agency failed to ensure the patient’s comprehensive assessments included changes that had occurred since the initial assessment or were updated every fifteen (15) days or that the hospice nurses are communicating changes in the patient’s condition or treatment to the Interdisciplinary Group as evidenced by: Review of the agencys policy entitled “;Wound Management” last reviewed 01/23/2024 revealed “;Open wounds will be assessed weekly and measured for length, width, and depth.” Patient #1 – This 83-year-old patient with a terminal diagnosis of Parkinsons disease without dyskinesia was admitted to the hospice on 10/11/2024. Review of the Registered Nurse Start of Care Visit Note dated 10/11/2024 revealed the patient has a sacral wound covered with allevyn dressing intact and a wound on the right heel. The Registered Nurse documented providing the following wound care to the right heel: - cleanse with soap and water - cover with gauze and kerlex, secure with tape A. Review of the clinical record lacks measurements of the heel from 10/13/2024 to 10/26/2024. During interview on 11/19/2024 at 10:00 AM, the Registered Nurse stated she did not know why the measurements were not documented. B. Review of the Registered Nurse Visit Note dated 10/13/2024 revealed the following measurement of the right heel wound: length 5.5 centimeters x width 4 centimeters. The measurement lacks a depth. During interview on 11/19/2024 at 10:00 AM, the Registered Nurse stated she was unable to measure a depth but should have put zero. Patient #15- This 95-year-old patient with a terminal diagnosis of unspecified lump in unspecified breast was admitted to the hospice on 11/29/2023. Review of the Registered Nurse Visit Note dated 12/14/2023 revealed the Registered Nurse documented, “;Multiple conversations with facility staff, charge nurse, and Administrator, the Hospice Director of Patient Services, and nursing supervisor related to how best to assess the patients injury and the patients safety... The Hospice Director of Patient Services has directed that the patient be discharged from hospice so the patient can receive care at the hospital. The Registered Nurse reviewed the facility staff and hospice concerns with the patients daughter who agreed with the plan.” Review of the clinical record lacks documented evidence that the physician was updated that the patient was discharged from hospice, to be evaluated for injury at the hospital and lacks orders for discharge. During interview on 11/20/2024 at 02:07 PM, the Director of Patient Services stated that the record lacks evidence that the physician was updated on the patients discharge and no discharge orders were received from the physician. Patient #16- This 74-year-old patient with a terminal diagnosis of amyotrophic lateral sclerosis was admitted to the hospice on 05/22/2024. Review of the Registered Nurse Visit Note dated 06/05/2024 revealed the Registered Nurse documented, “;The patient is being discharged from Hospice, the patient has opted to keep appointment today to get gastric tube redone.” Review of the clinical record lacks documented evidence that the physician was updated that the patient was discharged from hospice, to have percutaneous gastrostomy tube replaced with a mickey button gastrostomy tube and lacks orders for discharge. During interview on 11/20/2024 at 11:41 AM, the Registered Nurse stated that the physician was aware of the patients discharge but that was not documented in the record. The Registered Nurse also stated that discharge orders may not have been received due to planned re-admission to hospice services after the patients gastric tube change. The agency failed to ensure comprehensive assessments are updated and reflect the patient’s current status as evidenced by the following: Patient #11 – This 77-year-old patient with a terminal diagnosis of malignant neoplasm of the colon was admitted to the hospice on 09/26/2024. A.) Review of the Registered Nurse Start of Care Visit Note dated 09/26/2024 revealed the Registered Nurse documented the patient lives alone, is alert and oriented to person, place and time. Additionally, the Registered Nurse documented the patient is able to safely self-administer all ordered medications. Review of the Registered Nurse Routine Visit Notes for 10/02/2024, 10/04/2024, 10/07/2024 and 10/29/2024 revealed the Registered Nurse documented the patient is unable to safely self-administer all ordered medications. Review of the clinical record lacks documentation of an occurrence rendering the patient unsafe to self-administer all ordered medications. During interview on 11/20/2023 at 11:20 AM, the Registered Nurse stated the patient was independent with administering all medications at the identified visits and the Registered Nurse had made an error in the documentation. B.) Review of the Registered Nurse Routine Visit Note dated 10/24/2024 revealed the Registered Nurse documented the patient has two large skin tears on the right shin. The wound assessment to the right lower anterior leg shin/skin tear is documented as follows: - wound bed: clean, moist, granulating; - drainage: scant, serosanguinous color, no odor; - measurements: length 1 centimeter, width 2.5 centimeters, depth 0 centimeters. The Registered Nurse documented a second wound assessment to the right lower anterior leg shin/skin tear as follows: - wound bed: clean, moist; - drainage: scant, serosanguinous color, no odor; - measurements: length 1 centimeter, width 2.5 centimeters, depth 0 centimeters. The assessment lacks delineation of the two different wounds. During interview on 11/20/2024 at 11:25 AM, the Registered Nurse stated the two (2) wound beds were identical in size and description and was unaware how to differentiate the identified wound assessments. Patient #12 – This 75-year-old patient with a terminal diagnosis of chronic obstructive pulmonary disease was admitted to the hospice on 09/25/2024. Review of the Hospice Plan of Care for 09/25/2024 to 12/23/2024 revealed an order for Oxygen; “Other: 3.” Review of the Registered Nurse Routine Visit Note dated 10/23/2024 revealed the Registered Nurse documented the patient is experiencing tachypnea and is having continued shortness of breath. The Registered Nurse documented “;Patient reported having rough days Monday and Tuesday. Oxygen increased to 3.5 L (liters), saturation was good at 96% (percent) at todays visit.” Review of the Registered Nurse Routine Visit Note dated 10/30/2024 revealed the Registered Nurse documented the patient continues to have tachypnea, shortness of breath, will continue to use oxygen at 2 to 4 liters continuous. Review of the clinical record lacks documentation the physician and/or interdisciplinary group were notified of the patient using oxygen at a rate other than what is ordered. During interview on 11/20/2024 at 12:22 PM, the Registered Nurse stated that the Registered Nurse assumed that the patient’s order was for oxygen at 2 to 4 liters. Additionally, the Registered Nurse did not notify the physician and interdisciplinary group that the patient was using oxygen at a rate that was different than ordered. Patient #18 – This 66-year-old patient with a terminal diagnosis of malignant neoplasm of the endometrium was admitted to the hospice on 09/24/2024. A.) Review of the Registered Nurse Routine Visit Note dated 09/30/2024 revealed the Registered Nurse documented the patient has two (2) stage one pressure ulcers to the right and left buttocks and foam dressings were applied during the visit to each ulcer. Additionally, the Registered Nurse documented the patient has a right lower proximal leg abrasion/suspected deep tissue injury. Iodoform gauze covered with a non-adherent dressing and kling was applied to the area. Review of the clinical record lacks wound care orders for the right and left buttocks and right lower proximal leg wound. During interview on 11/19/2024 at 12:07 PM, the Registered Nurse stated the physician and/or interdisciplinary were not notified of the status of the wounds at the identified visit and orders were not obtained for the wound care interventions that were performed. B.) Review of the Registered Nurse Routine Visit Note dated 10/01/2023 revealed the Registered Nurse documented: - Integumentary: decubitus/pressure ulcer. The documentation lacks an assessment and interventions to the right and left buttocks pressure ulcers and right lower proximal leg abrasion/suspected deep tissue injury identified in the 09/30/2024 nursing visit. Review of the Interdisciplinary Group Meeting dated 10/02/2024 lacks a discussion regarding interventions being developed for the right and left buttocks pressure ulcers and the right lower proximal leg wound. During interview on 11/20/2024 at 11:49 AM, the Registered Nurse stated the identified wounds were not assessed during the visit. It was also unclear when wound assessments and dressing changes were to occur because no wound care orders were established. The Registered Nurse stated the interdisciplinary group was not updated at the 10/02/2024 meeting regarding the lack of wound care orders for all the identified wounds. C.) Review of the Registered Nurse Routine Visit Note dated 10/04/2024 revealed the following wound assessments: - Left upper buttocks/coccyx/decubitus/pressure ulcer stage II: wound bed clean, moist, and red, no drainage, wound bed cleansed with soap and water and left open to air. Barrier cream to the area two (2) times a day and PRN (as needed). - Right upper buttocks coccyx/decubitus/pressure ulcer stage II: wound bed clean, moist and red, wound bed cleansed with soap and water and left open to air. Barrier cream to the area two (2) times a day and PRN (as needed). - Right lower anterior proximal leg shin abrasion stage II- wound bed clean, moist and red. The assessment lacks documentation of drainage for the right upper buttocks and right lower anterior proximal leg wounds. The assessment lacks documentation of follow-up with the physician and/or interdisciplinary group on the identified wounds, and evidence orders were obtained for the care of the three wounds. During interview on 11/20/2024 at 11:53 AM, the Registered Nurse stated the physician and interdisciplinary group were not notified of the status of the three (3) wounds status, and wound care orders were not obtained. Patient #19 – This 86-year-old patient residing in a skilled nursing facility with a terminal diagnosis of alzheimers disease, late onset was admitted to the hospice on 07/12/2024. A.) Review of the Hospice Plan of Care for 07/12/2024 to 10/09/2024 revealed the patient has type 2 diabetes mellitus and is to take lantus 100 units per milliliter; inject 10 units per milliliter subcutaneous daily. Review of the Registered Nurse Routine Visit Note dated 07/15/2024 revealed the Registered Nurse documented the patient is eating and drinking poorly. The patient takes lantus and has orders for regular blood glucose testing, which run between 134 and 315. Review of the clinical record lacks documentation the physician and/or interdisciplinary group were notified of the patients poor oral intake or that there was a discussion regarding continued insulin administration or a need to add parameters to notify the physician for abnormal blood sugar values. During interview on 11/20/2024 at 10:05 AM, the Registered Nurse stated being unable to recall why the physician or interdisciplinary were not notified of the patients poor oral intake while taking insulin therapy. B.) Review of the Registered Nurse Routine Visit Note dated 07/16/2024 revealed the Registered Nurse documented the patients left lower heel stage II pressure ulcer had a black center, that appeared to be attached at the edges, with a red perimeter and strong and foul odor. The Registered Nurse documented the following recommendation made to the Skilled Nursing Facility staff: “;Advised changing treatment to medi honey vs. (versus) santyl.” Review of the Registered Nurse Routine Visit Note dated 07/18/2024 revealed the Registered Nurse documented left lower heel dressing is clean, dry and intact. The assessment lacks documentation regarding follow-up of wound care recommendations made on 07/16/2024. Review of the clinical record lacks documentation the Registered Nurse contacted the physician and/or communicated with the interdisciplinary group regarding the recommendations to change the wound care orders. During interview on 10/20/2024 at 10:22 AM, the Registered Nurse stated the skilled nursing facility physician was notified of the wound care recommendations, but the Registered Nurse failed to document this. C.) Review of the Registered Nurse Routine Visit Note dated 07/23/2024 revealed the Registered Nurse documented “;Per LPN (Licensed Practical Nurse) patient has needed two doses of PRN (as needed) morphine since the shift started to address non-verbal indicators of pain (moaning, wincing, restlessness). Podiatrist was in the facility today and feels that patient is having so much pain because the wound on the heel is vascular. The dressing has already been changed, but the odor is still strong. Family and staff educated related to using PRN (as needed) lorazepam to potentiate morphine.” Additionally, the Registered Nurse documented the physician would be contacted to obtain an order for flagyl to put in in the wound. Review of the Interdisciplinary Group Meeting dated 07/24/2024 lacks documentation of a discussion regarding the patient’s wound pain and status along with the podiatrist’s concerns and recommendations for medication changes. Review of the clinical record lacks documentation of orders for flagyl and lorazepam. During interview on 11/20/2024 at 12:18 PM, the Director of Patient Services stated the Registered Nurse was unavailable for interview. The Director of Patient Services stated the Registered Nurse failed to update the Interdisciplinary Group of the identified changes. Additionally, the Director of Patient Services stated orders were not obtained for lorazepam and flagyl.”

“Based on review of clinical records and interviews with staff for eight (8) of nineteen (19) clinical records (Patient #s: 10, 11, 12, 13, 14, 16, 18, and 19) the hospice failed to include all core services at each Interdisciplinary Group meeting. Failure to ensure all core services represented at the Interdisciplinary Group meeting may compromise care and services offered to the patient. The hospice failed to include all core services at each Interdisciplinary Group meeting as evidenced by the following: Patient #13 – This 61-year-old patient with a terminal diagnosis of malignant neoplasm of appendix was admitted to the hospice on 09/19/2024. Review of the Interdisciplinary Group Meeting dated 10/02/2024 lacks documented evidence the chaplain was in attendance. During interview on 11/19/2024 at 03:39 PM, the Director of Patient Services stated the chaplain was there but did not know how to sign the attendance sheet, so the signature line is blank. Patient #14 – This 90-year-old patient with a terminal diagnosis of malignant neoplasm of prostate was admitted to the hospice on 08/14/2024. Review of the Interdisciplinary Group Meeting dated 10/02/2024 lacks documented evidence the chaplain was in attendance. During interview on 11/19/2024 at 03:340 PM, the Director of Patient Services stated the chaplain was there but did not know how to sign the attendance sheet, so the signature line is blank. Patient #10- This 95-year-old patient with a terminal diagnosis of hypertensive heart and chronic kidney disease with heart failure was admitted to the hospice on 10/03/2024. Review of the Interdisciplinary Group Meetings dated 10/15/2024 and 10/30/2024 lacks documented evidence the Registered Nurse was in attendance. During interview on 11/20/2024 at 11:06 AM, the Director of Patient Services stated that the Registered Nurse was present for both meetings. The Director of Patient Services further stated that the hospice will be looking into this, as there may be a technical issue that needs to be resolved. Patient #16- This 74-year-old patient with a terminal diagnosis of amyotrophic lateral sclerosis was admitted to the hospice on 05/22/2024. Review of the Interdisciplinary Group Meeting dated 05/29/2024 lacks documented evidence the Medical Director was in attendance. During interview on 11/20/2024 at 03:02 PM, the Director of Patient Services stated that the Medical Director was present at the meeting, but there is no signature, and this may be another technical issue. The hospice failed to include all core services at each Interdisciplinary Group meeting as evidenced by the following: Patient #11 – This 77-year-old patient with a terminal diagnosis of malignant neoplasm of the colon was admitted to the hospice on 09/26/2024. A.) Review of the Interdisciplinary Group Meeting dated 10/02/2024 lacks documented evidence the chaplain was in attendance. During interview on 11/19/2024 at 02:53 PM, the Supervising Public Health Nurse stated the chaplain was present for the meeting but failed to complete the attendance sheet electronically. B.) Review of the Interdisciplinary Group Meeting dated 11/13/2024 lacks documented evidence the physician was in attendance. During interview on 11/19/2024 at 02:59 PM, the Director of Patient Services stated the physician was present for the meeting but failed to electronically sign the attendance sheet. Patient #12 – This 75-year-old patient with a terminal diagnosis of chronic obstructive pulmonary disease was admitted to the hospice on 09/25/2024. Review of the Interdisciplinary Group Meeting dated 10/02/2024 lacks documented evidence the chaplain was in attendance. Patient #18 – This 66-year-old patient with a terminal diagnosis of malignant neoplasm of the endometrium was admitted to the hospice on 09/24/2024. Review of the Interdisciplinary Group Meeting dated 10/02/2024 lacks documented evidence the chaplain was in attendance. During interview on 11/19/2024 at 03:16 PM, the Director of Patient Services stated the chaplain was present for the meeting but failed to electronically sign the attendance sheet. Patient #19 – This 86-year-old patient residing in a skilled nursing facility with a terminal diagnosis of alzheimers disease, late onset was admitted to the hospice on 07/12/2024. Review of the Interdisciplinary Group Meeting dated 07/24/2024 lacks documented evidence the chaplain was in attendance. During interview on 11/20/2024 at 12:46 AM, the Director of Patient Services stated the chaplain was present for the meeting but failed to electronically sign the attendance sheet.”

“Based on review of clinical records and interviews with staff for four (4) of nineteen (19) clinical records (Patient #’s: 1, 8, 14, and 18) the hospice failed to provide services according to the Plan of Care. Failure to provide services in accordance with the Plan of Care has the potential for unmet patient needs. The hospice failed to provide services according to the Plan of Care as evidenced by: Patient #18 – This 66-year-old patient with a terminal diagnosis of malignant neoplasm of the endometrium was admitted to the hospice on 09/24/2024. Review of the Hospice Plan of Care for 09/24/2024 to 12/22/2024 revealed the following discipline orders: - Skilled Nursing to assess and evaluate 09/23/2024 through 09/27/2024; - Skilled Nursing once a day for one (1) week for one (1) week from 09/25/2024 to 09/28/2024; and - Skilled Nursing one (1) to five (5) visits a week, for thirteen (13) weeks with twenty (20) as needed visits for symptom management or changes in condition in regards to end of life care, beginning during week of 09/26/2024. Review of the clinical record revealed two Skilled Nursing Visits were completed during the week of 09/22/2024 to 09/28/2024. The visits occurred on 09/24/2024 and 09/27/2024. There is no documentation to explain why the patient did not receive a daily visit as ordered for the week. During interview on 11/19/2024 at 12:37 PM, the Director of Patient Services stated the Registered Nurse that developed the plan of care no longer works for the hospice. The Director of Patient Services stated that they would look for additional information to explain the visit frequency. No further information was provided. The hospice failed to provide services according to the Plan of Care as evidenced by: Patient #1 – This 83-year-old patient with a terminal diagnosis of Parkinsons disease without dyskinesia was admitted to the hospice on 10/11/2024. Review of the Hospice Plan of Care for 10/11/2024 to 01/08/2025 revealed the order for the Skilled Nurse to monitor vital signs. Review of the Registered Nurse Start of Care Visit Note dated 10/11/2024 lacks documentation of a blood pressure and heart rate. During interview on 11/19/2024 at 09:45 AM, the Registered Nurse stated vital signs include blood pressure, heart rate, respirations, and temperature and all should be obtained at the start of care. The Registered Nurse stated being unable to obtain a blood pressure because the cuff had a hole in it. Additionally, the Registered Nurse stated that the patient’s heart was auscultated, but a heart rate was not obtained. Patient #8 – This 34-year-old patient with a terminal diagnosis of malignant neoplasm of the rectum receiving inpatient hospice services at a local hospital was admitted to the hospice on 10/22/2024. Review of the Hospice Plan of Care for 10/22/2024 to 01/09/2025 revealed the following order: “;Skilled Nurse assess gastrointestinal status including bowel sounds and bowel elimination patterns.” Review of the Registered Nurse Start of Care Visit Note dated 10/22/2024 revealed the patient has an ostomy but lacks an assessment of the site and the ostomy itself. Review of the Registered Nurse Routine Visit Notes dated 10/23/2024, 10/24/2024, and 10/25/2024 lacks evidence of an assessment of the ostomy site and the ostomy itself. During interview on 11/20/2024 at 09:42 AM, the Registered Nurse stated the hospital staff are responsible for the ostomy, and the patient refused gastrointestinal assessments by the Hospice Nurse, but the Registered Nurse failed to document the refusals. Patient #14 – This 90-year-old patient with a terminal diagnosis of malignant neoplasm of prostate was admitted to the hospice on 08/14/2024. Review of the Hospice Plan of Care for 08/14/2024 to 11/11/2024 revealed the order for the aide to provide services 1 to 5 times a week. Review of the clinical record from 09/08/2024 to 09/21/2024 lacks documented evidence the aide provided services. During interview on 11/19/2024 at 03:42 PM, the Director of Patient Services stated the aide was on vacation and they had no one to fill in. The agency will obtain an order to pause services during that time.”

“Based on a review of clinical records and interview with agency staff for one (1) of nineteen (19) patients (Patient #11) the agency failed to ensure the patient and/or caregiver received education and training identified in the Plan of Care. Failure to provide appropriate education and training to patients and caregivers has the potential to result in negative patient outcomes. The hospice failed to provide appropriate education and training as evidenced by the following: Patient #11 – This 77-year-old patient with a terminal diagnosis of malignant neoplasm of the colon was admitted to the hospice on 09/26/2024. A.) Review of the Registered Nurse Routine Visit Note dated 10/27/2024 revealed the patient has a new complaint of mouth pain. The Registered Nurse documented that the patient’s oral mucosa is pink with no evidence of thrush, but patient states it hurts to swallow and is hard to eat. Review of the Registered Nurse Non-Reportable/Non Billable Note dated 10/28/2024 revealed the Registered Nurse documented that new orders were obtained for nystatin and magic mouthwash which would be delivered to the patient on 10/29/2024. Additionally, the Registered Nurse documented “;reviewed how to use nystatin.” Review of the Registered Nurse Routine Visit Note dated 10/29/2024 revealed the Registered Nurse documented that no medication interventions were performed during the visit as there is no evidence of a medication change since the last review. The visit note lacks documentation that education was provided to the patient on the new medications, nystatin and magic mouthwash. During interview on 11/20/2024 at 11:30 AM, the Registered Nurse stated education was provided on the two new medications during the identified visit but it was not documented. B.) Review of the Patient Care Order (Verbal Order) dated 10/29/2024 revealed the wound (not specified) is to be washed with warm water and soap as tolerated, covered with xeroform and tegaderm twice weekly and as needed until healed. Review of the Registered Nurse Routine Visit Note dated 10/29/2024 revealed the Registered Nurse documented the leg dressing was removed and recommendations were made to leave the right lower shin skin tears open to air for the next several hours to “;help dry them out.” Review of the clinical record lacks documentation the patient and/or caregiver were instructed and successfully re-demonstrated the ordered wound care. During interview on 11/20/2024 at 11:32 AM, the Registered Nurse stated the patient was taught to perform the identified dressing change to the right lower shin skin tears but it was not documented.”

“Based on review of clinical records and interviews with staff, for twelve (12) of nineteen (19) patients (Patient #’s: 1, 3, 4, 6, 8, 11, 12, 15, 16, 17, 18, and 19) the hospice failed to develop an individualized written Plan of Care that reflects the patient and family goals and is based on the problems identified in the initial and updated comprehensive assessments. Failure to develop complete, individualized plans of care has the potential for unmet patient needs and health status to be compromised, resulting in poor quality of care. Patient #15- This 95-year-old patient with a terminal diagnosis of unspecified lump in unspecified breast was admitted to the hospice on 11/29/2023. Review of the Hospice Plan of Care for 11/29/2023 to 02/26/2024 revealed the patients activity level is; up as tolerated with a walker. Review of the Hospice Plan of Care lacks an order for a walker. During interview on 11/20/2024 at 01:59 PM, the Director of Patient Services stated that the walker should be on the Plan of Care, but is not. Patient #16- This 74-year-old patient with a terminal diagnosis of amyotrophic lateral sclerosis was admitted to the hospice on 05/22/2024. Review of the referral to the agency dated 05/20/2024 revealed the following orders: - bolus feeding supply kit- for gastrostomy tube feedings - cough assist- twice daily, auto mode, cough trek on, start +30/-30, titrate to comfort up to +40/-40. - suction machine with yankauer adapter for oral secretion management. - nutritional supplements; kate farms standard 1.4 calorie liquid, 1 (one) carton, 4 (four) times daily by gravity. Review of the Hospice Plan of Care for 05/22/2024 to 08/19/2024 lacks order for the durable medical equipment and supplies. During interview on 11/19/2024 at 10:52 AM, the Registered Nurse stated that all the patients durable medical equipment and supplies should be listed on the Plan of Care. The Registered Nurse further stated that the patient was using all the durable medical equipment and supplies independently, so the Registered Nurse forgot and did not add the orders to the Plan of Care. Patient #17- This 78-year-old patient with a terminal diagnosis of hypertensive heart and chronic kidney disease with heart failure was admitted to the hospice on 12/22/2023. Review of the “;Initial Hospice Evaluation” dated 12/22/2023, the Registered Nurse documented that the patient had the following durable medical equipment in the home: hospital bed with alternating pressure positioning mattress, oxygen, wheeled walker, and wheelchair. Review of the Hospice Plan of Care for 12/22/2023 to 03/20/2024 lacks orders for the alternating pressure positioning mattress, wheeled walker, and wheelchair. During interview on 11/19/2024 at 10:06 AM, the Registered Nurse stated that it is unclear why, but there is durable medical equipment missing on the Plan of Care. Also, at 10:06 AM, the Director of Patient Services stated that what happened on the Plan of Care order, that it looks like there is information that was cut off, and the hospice will need to look at that issue. 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 as evidenced by: Patient #11 – This 77-year-old patient with a terminal diagnosis of malignant neoplasm of the colon was admitted to the hospice on 09/26/2024. A.) Review of the Hospice Plan of Care for 09/26/2024 to 12/24/2024 revealed the following orders: - lorazepam 0.5 milligram tablet; take 1 (one) tab orally every 4 (four) hours as needed for anxiety; and - lorazepam 2 milligram/milliliter oral concentrate; administer 0.25 to 0.5 milliliter(s) orally every 4 (four) hours as needed for anxiety. It is unclear whether the patient is to take the tablet and liquid medications concurrently as there are unclear instructions for administration of the medication. During interview on 11/20/2024 at 11:28 AM, the Registered Nurse stated the order was written incorrectly and is supposed to specify to take the liquid form of the medication when the patient is no longer able to swallow the tablet form. B.) Review of the hospices Determination of Eligibility Form dated 09/26/2024 revealed the patients primary diagnosis is colon cancer. Review of the Hospice Plan of Care for 09/26/2024 to 12/24/2024 revealed the primary diagnosis is listed as: other specified diseases of intestine. The plan of care lacks a diagnosis of colon cancer. During interview on 11/19/2024 at 12:26 PM, the Supervising Public Health Nurse stated being unaware of a specific code for colon cancer and as a result the plan of care failed to include the correct primary diagnosis. Patient #12 – This 75-year-old patient with a terminal diagnosis of chronic obstructive pulmonary disease was admitted to the hospice on 09/25/2024. A.) Review of the Hospice Plan of Care for 09/25/2024 to 12/23/2024 revealed the following order: Supplies: Oxygen, other: 3. The order lacks specification of liter flow, frequency, delivery device, and duration of use. During interview on 11/19/2024 at 11:54 AM, the Registered Nurse stated the identified oxygen order was incomplete. B.) Review of the Hospice Plan of Care for 09/25/2024 to 12/23/2024 revealed an order for ipratropium 500 microgram per 2.5 milliliter inhalation solution, inhale 2.5 inhalation by nebulizer 4 (four) times a day as needed for shortness of breath. Review of the Hospice Plan of Care for 09/25/2024 to 12/23/2024 lacks an order for a nebulizer machine. During interview on 11/19/2024 at 11:55 AM, the Registered Nurse stated the patient has a nebulizer machine and this was accidentally omitted from the plan of care. C.) Review of the Hospice Plan of Care for 09/25/2024 to 12/23/2024 revealed an order for Medical Social Worker to assess and evaluate 09/25/2024 to 10/01/2024. Review of the Medical Social Worker Assessment dated 09/27/2024 revealed the initial social work visit was conducted on 09/27/2024. Review of the Patient Care Order (Verbal Order) dated 10/01/2024 revealed the order for Medical Social Worker 1 (one) to 3 (three) visits per month for 3 (three) months. The order to develop the plan of care lacks interventions and goals for social work services. During interview on 11/19/2024 at 02:09 PM, the Licensed Master Social Worker stated being unaware that the interventions and goals were not on the plan of care for the discipline. Patient #18 – This 66-year-old patient with a terminal diagnosis of malignant neoplasm of the endometrium was admitted to the hospice on 09/24/2024. A.) Review of the Registered Nurse Start of Care Visit Note dated 09/24/2024 revealed the Registered Nurse documented the patient has a right lower anterior proximal leg abrasion/suspected deep tissue injury that was cleansed the wound with sterile saline, medihoney was applied along with a non-adherent dressing that was covered with kling. The Registered Nurse documented the right lower leg wound is approximately two (2) months old, has been treated with medihoney,”;but will try switching to xeroform.” Review of the Hospice Plan of Care for 09/24/2024 to 12/22/2024 revealed there are no treatment orders for the right lower anterior proximal leg abrasion/suspected deep tissue injury. During interview on 11/19/2024 at 12:33 PM, the Director of Patient Services stated the Registered Nurse no longer works for the hospice. The Director of Patient Services stated the plan of care fails to include wound care orders for the right lower leg identified in the admission assessment. B.) Review of the Hospice Plan of Care for 09/24/2024 to 12/22/2024 lacks documentation that a verbal order was obtained from the attending physician to initiate hospice services. During interview on 11/19/2024 at 12:37 PM, the Director of Patient Services stated the Registered Nurse that conducted the admission no longer works for the hospice. The Director of Patient Services stated additional information would be looked for regarding the verbal order. No further documentation was provided. Patient #19 – This 86-year-old patient residing in a skilled nursing facility with a terminal diagnosis of alzheimers disease, late onset was admitted to the hospice on 07/12/2024. A.) Review of the Registered Nurse Start of Care Visit Note dated 07/12/2024 revealed blood glucose monitoring occurs prior to meals and the patient is unable to self-test. Review of the Hospice Plan of Care for 07/12/2024 to 10/09/2024 revealed the patient has a diagnosis of type 2 diabetes mellitus and is to take lantus 100 units per milliliter, inject 10 units per milliliter subcutaneous daily. There are no orders for diabetic supplies, documentation about the individual(s) responsible for performing the blood glucose testing and insulin administration, or blood glucose parameters requiring physician notification. During interview on 11/19/2024 at 11:18 AM, the Registered Nurse stated the skilled nursing facility staff provide all diabetic care and follow-up to the patient and the Registered Nurse unaware this should be included on the hospice plan of care. B.) Review of the Hospice Plan of Care for 07/12/2024 to 10/09/2024 revealed an order for Santyl 250 units per gram topical ointment, apply 1 (one) application topical once a day. The order does not specify to specify the site of application. During interview on 11/19/2024 at 11:19 AM, the Registered Nurse stated the order did not include the location for application. C.) Review of the Hospice Plan of Care for 07/12/2024 to 10/09/2024 revealed an order for nystop 100,000 units per gram topical powder, apply 100,000 application topical 2 (two) times a day. The order fails to specify the quantity and the location to apply the topical powder. During interview on 11/19/2024 at 11:29 AM, the Registered Nurse stated the order was incomplete and was not able to recall why a complete order was not written. D.) Review of the Hospice Plan of Care for 07/12/2024 to 10/09/2024 revealed an order for Skin Care: Instruct family/primary caregiver to use barrier cream to affected areas to prevent skin breakdown and to maintain skin integrity prn (as needed). The plan of care lacks an order for the barrier cream to be applied. During interview on 11/19/2024 at 11:40 AM, the Registered Nurse stated it was an oversight that the barrier cream was not included on the plan of care. 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 as evidenced by: Patient #1 – This 83-year-old patient with a terminal diagnosis of Parkinsons disease without dyskinesia was admitted to the hospice on 10/11/2024. A. Review of the Registered Nurse Start of Care Visit Note dated 10/11/2024 revealed the patient has a sacral wound covered with allevyn dressing intact and a wound on the right heel. The Registered Nurse documented providing the following wound care to the right heel: - cleanse with soap and water - cover with gauze and kerlex, secure with tape Review of the Hospice Plan of Care for 10/11/2024 to 01/08/2025 lacks orders for wound care. During interview on 11/19/2024 at 09:45 AM, the Registered Nurse stated they thought they called for wound care orders, but did not document a call or wound care orders. B. Review of the Hospice Plan of Care for 10/11/2024 to 01/08/2025 lacks an order to start hospice services. During interview on 11/19/2024 at 12:21 PM, the Supervising Public Health Nurse stated a verbal order was obtained but it was not documented. Patient #4 – This 58-year-old patient with a terminal diagnosis of acute respiratory failure was admitted to the hospice on 11/06/2024. A. Review of the Hospice Plan of Care for 11/06/2024 to 02/03/2025 revealed the patient is ordered to receive Social Work services one to three times a month for three months but lacks orders for interventions to be completed by the Social Worker. During interview on 11/19/2024 at 02:20 PM, the Licensed Master Social Worker stated the interventions were created after the first visit on 11/07/2024 but does not know why they werent on the plan of care. B. Review of the Hospice Plan of Care for 11/06/2024 to 02/03/2025 lacks an order to start hospice services. During interview on 11/19/2024 at 02:22 PM, the Supervising Public Health Nurse stated a verbal order was obtained but it was not documented. Patient #3 – This 93-year-old patient with a terminal diagnosis of Alzheimers disease was admitted to the hospice on 11/07/2024. Review of the Hospice Plan of Care for 11/07/2024 to 02/04/2025 lacks an order to start hospice services. During interview on 11/19/2024 at 12:18 PM, the Supervising Public Health Nurse stated a verbal order was obtained but it was not documented. Patient #6 – This 95-year-old patient with a terminal diagnosis of pathological fracture right femur sequela was admitted to the hospice on 11/01/2024. Review of the Hospice Plan of Care for 11/01/2024 to 01/29/2025 lacks an order to start hospice services. During interview on 11/19/2024 at 03:31 PM, the Supervising Public Health Nurse stated a verbal order was obtained but it was not documented. Patient #8 – This 34-year-old patient with a terminal diagnosis of malignant neoplasm of the rectum receiving inpatient hospice services at a local hospital was admitted to the hospice on 10/22/2024. Review of the Registered Nurse Start of Care Visit Note dated 10/22/2024 revealed the patient has an ostomy. Review of the Hospice Plan of Care for 10/22/2024 to 01/09/2025 lacks an order for ostomy care or supplies. During interview on 11/20/2024 at 09:42 AM, the Registered Nurse stated the hospital staff are responsible for the patients ostomy but stated there should have been some reference to the ostomy on the Plan of Care.”

“Based on review of clinical records and interviews with staff, the hospice failed to ensure in eight (8) of nineteen (19) patients (Patient #s: 1, 10, 11, 14, 15, 17, 18, and 19) that care and services are provided in accordance with 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. The agency failed to obtain orders to provide services as evidenced by the following: Patient #1 – This 83-year-old patient with a terminal diagnosis of Parkinsons disease without dyskinesia was admitted to the hospice on 10/11/2024. A. Review of the Registered Nurse Visit Note dated 10/24/2024 revealed the Registered Nurse documented “;Foley catheter inserted today due to incontinence and large sacral ulcer.” Review of the clinical record lacks an order for a foley catheter. During interview on 11/20/2024 at 12:10 PM, the Registered Nurse stated there is no order for the foley, one will be obtained. B. Review of the Patient Care Order (Verbal Order) dated 10/21/2024 revealed: - Decubitus/pressure ulcer stage II/lower foot heel. Place allevyn foam dressing over area and wrap with kerlex. Change two times a week or as needed. Review of the Registered Nurse Routine Visit Note dated 10/21/2024 revealed the Registered Nurse cleansed the wound with soap and water. The order lacks specification of which heel the wound is on and instructions for cleansing the wound. During interview on 11/20/2024 at 12:05 PM, the Registered Nurse stated she would clarify and update the order. C. Review of the Patient Care Order (Verbal Order) dated 10/21/2024 revealed: - Decubitus/pressure ulcer stage III. Clean the peri wound area with warm water and soap, pat dry, and cover with large sacral dressing every three days and as needed. Do not apply any creams or lotion to area. Review of the Registered Nurse Routine Visit Note dated 10/21/2024 revealed the Registered Nurse provided wound care to the sacral area using and allevyn dressing. The order lacks the location of the wound and what specific sacral dressing is used. During interview on 11/20/2024 at 12:05 PM, the Registered Nurse stated she would clarify and update the order. Patient #14 – This 90-year-old patient with a terminal diagnosis of malignant neoplasm of prostate was admitted to the hospice on 08/14/2024. A. Review of the Registered Nurse Routine Visit Note dated 10/08/2024 revealed the Registered Nurse documented “;patient is doing fine and wants to visit with the volunteer today.” Review of the clinical record lacks an order for volunteer services. During interview on 11/19/2024 at 03:44 PM, the Director of Patient Services stated there is no order for the volunteer. B. Review of the Registered Nurse Routine Visit Note dated 11/01/2024 revealed the Registered Nurse documented the following wound care for two new wounds: - left distal arm elbow/skin tear - cleansed with soap and water - covered with allevyn - right upper arm tricep/skin tear - cleansed with soap and water - covered with allevyn Review of the clinical record lacks an order for the wound care. During interview on 11/20/2024 at 12:32 PM, the Registered Nurse stated no orders for the wounds were obtained. Patient #7 - This 98-year-old patient with a terminal diagnosis of congestive heart failure was admitted to the hospice on 10/25/2024. Review of the Registered Nurse Routine Visit Note dated 10/29/2024 revealed the Registered Nurse documented “;Denies pain although has on occasion pain in right hip. Does get CBD (Cannabidiol) oil once a day for this as well as Tylenol as needed with good effect.” Review of the clinical record lacks documented evidence of an order for Cannabidiol. During interview on 11/20/2024 at 12:35 PM, the Registered Nurse stated there is no order for the Cannabidiol. The agency failed to obtain orders to provide services as evidenced by the following: Patient #11 – This 77-year-old patient with a terminal diagnosis of malignant neoplasm of the colon was admitted to the hospice on 09/26/2024. Review of the Registered Nurse Routine Visit Note dated 10/24/2024 revealed the Registered Nurse documented the patient has two, new, large skin tears on the right shin. The Registered Nurse documented performing wound care to both skin tears during the visit to include: cleansing wounds with soap and water, covering each wound with a non-adherent dressing, and covering with a tegaderm dressing. Review of the clinical record lacks orders for wound care to the two (2) right lower extremity skin tears. During interview on 11/20/2024 at 11:26 AM, the Registered Nurse stated the physician was notified of the new wounds and the wound care performed on 10/24/2024 but stated an oversight was made and the order for the wound care was not obtained. Patient #18 – This 66-year-old patient with a terminal diagnosis of malignant neoplasm of the endometrium was admitted to the hospice on 09/24/2024. A.) Review of the Registered Nurse Routine Visit Note dated 09/27/2024 revealed the Registered Nurse documented the patient has a left upper buttocks stage one pressure ulcer and a right upper buttocks stage one pressure ulcer. The Registered performed the following wound care to both buttocks wounds: cleansed with soap and water and applied foam adhesive. Review of the Registered Nurse Routine Visit Note dated 09/30/2024 revealed the Registered Nurse documented the patient has a left upper buttocks stage one pressure ulcer and a right upper buttocks stage one pressure ulcer. The Registered performed the following wound care to both buttocks wounds: cleansed with soap and water and applied foam adhesive. Review of the clinical record lacks orders for wound care to the right and left buttocks pressure ulcers. During interview on 11/19/2024 at 12:08 PM, the Registered Nurse stated an order for the identified wound care failed to be obtained. B.) Review of the Registered Nurse Routine Visit Note dated 09/27/2024 revealed the Registered Nurse documented the patient has a right lower anterior leg abrasion/deep tissue injury and performed the following wound care to the area: cleansed with normal saline, applied iodoform gauze covered with a non-adherent dressing and kling. Review of the Registered Nurse Routine Visit Note dated 09/30/2024 revealed the Registered Nurse documented the patient has a right lower anterior leg abrasion/deep tissue injury and performed the following wound care to the area: cleansed with normal saline, applied iodoform gauze covered with a non-adherent dressing and kling. Review of the clinical record lacks orders for wound care to the right lower anterior leg abrasion/deep tissue injury. During interview on 11/19/2024 at 12:12 PM, the Registered Nurse stated an order for the identified wound care failed to be obtained. Patient #19 – This 86-year-old patient residing in a skilled nursing facility with a terminal diagnosis of alzheimers disease, late onset was admitted to the hospice on 07/12/2024. Review of the Hospice Plan of Care for 07/12/2024 to 10/09/2024 revealed an order for santyl 250 units per gram topical ointment, apply 1 (one) application topical once a day. The order fails to specify the location to apply the ointment. Review of the Registered Nurse Routine Visit Note dated 07/15/2024 revealed the Registered Nurse documented that the Licensed Practical Nurse at the facility reports the patient appears to be having more pain with dressing changes than previously. Additionally, the patient tensed up when the Registered Nurse adjusted the bootie placed on the foot. Review of the clinical record lacks wound care orders. During interview on 11/20/2024 at 10:03 AM, the Registered Nurse stated the wound that was referenced in the 07/15/2024 visit was to the patients stage 2 (two) pressure ulcer on the left heel and the facility staff were performing santyl dressing changes to the area daily. Additionally, the Registered Nurse stated being unaware that the order for the santyl dressing changes was incomplete on the plan of care. Patient #10- This 95-year-old patient with a terminal diagnosis of hypertensive heart and chronic kidney disease with heart failure was admitted to the hospice on 10/03/2024. The hospice failed to ensure services are provided in accordance with the plan of care as evidenced by the following: A. Review of the Verbal Order dated 10/15/2024 for ondansetron 4 milligrams, 1 (one) tablet, orally, every 8 (eight) hours as needed for nausea revealed the medication was started on 10/15/2024. The order was not signed/authenticated by the Registered Nurse until 11/04/2024, twenty days after the medication was started. B. Review of the Verbal Order dated 10/15/2024 for oxycodone 5 milligrams, 1 (one) tablet, orally, every 6 (six) hours as needed for pain and tylenol 500 milligrams, 1 (one) to 2 (two) tablets, orally, every 8 (eight) hours as needed for pain revealed the order was received 10/15/2024 at 03:55 PM, but was not signed/authenticated by the Registered Nurse until 11/04/2024. C. Review of the Verbal Order dated 10/15/2024 revealed the following: -MiraLAX 17 grams, 17grams, orally, once daily for constipation, start date: 10/15/2024; - discontinue- effective 10/15/2024- oxycodone 5 milligrams, 1 (one) tablet, orally, every 6 (six) hours as needed for pain - discontinue- effective 10/15/2024- tylenol 500 milligrams, 1 (one) to 2 (two) tablets, orally, every 8 (eight) hours as needed for pain The order was not signed/authenticated by the Registered Nurse until 11/04/2024 at 04:00 PM, 20 (twenty) days after the order was received. Review of the Interdisciplinary Group Meetings dated 10/16/2024 and 10/30/2024 lacks documented evidence of a discussion regarding the medication changes. During interview on 11/202/2024 at 10:56 AM, the Registered Nurse stated that hospice expectation for verbal orders is that the orders be completed immediately or as soon as possible. The Registered Nurse further stated that the verbal orders on 10/15/2024 should have been signed sooner but the Registered Nurse did not document timely. At 10:57 AM, the Director of Patient Services stated that orders cannot be added to the record until the clinician signs the order, and that if the verbal orders from 10/15/2024 had been signed, the new orders would have been updated on the Interdisciplinary Group Meeting medication lists on 10/16/2024 and 10/30/2024. Patient #17- This 78-year-old patient with a terminal diagnosis of hypertensive heart and chronic kidney disease with heart failure was admitted to the hospice on 12/22/2023. This patient resides in a Skilled Nursing Facility. A. Review of the Registered Nurse Visit Note dated 12/22/2023 revealed the Registered Nurse documented the following: Clinical Findings: Integumentary: Not assessed this visit. Patient has a small dressing on left upper arm that is clean, dry, and intact. Patient has an order for a dry dressing to sacrum and buttocks. Patient was tired at end of the visit and areas were not assessed today. Review of the Hospice Plan of Care for 12/22/2023 to 03/202024 revealed an order for Skin care; to instruct the family/ primary caregiver to use barrier cream to affected areas to prevent skin breakdown and maintain skin integrity as needed. There is no order for a dressing to the left upper arm or the sacrum and buttocks. During interview on 11/19/2024 at 11:09 AM, the Registered Nurse stated that the patients skin was not assessed at the visit because the patient declined the assessment, the Registered Nurse could not remember what dressing orders the patient had, but that the Plan of Care should have been updated with the correct order, not just the “;Standing Order” for skin care. B. Review of a Verbal Order dated 12/26/2023, revealed the following order was received on 12/26/2023 but was not signed/authenticated by the Registered Nurse until 01/05/2024, 10 (ten) days after the orders were received: - albuterol- ipratropium 2.5 milligrams- 0.5 milligrams per 3 milliliters inhalation solution, inhale 1 (one) unit by nebulizer 4 (four) times daily as needed for shortness of breath; read back and confirmed; start date: 12/26/2023 - discontinue- effective 12/26/2023: folic acid 0.4 milligrams, 1 (one) tablet, orally, once daily - discontinue- effective 12/26/2023: Cholecalciferol 1000 units, 1 (one) capsule, orally, once daily - discontinue- effective 12/26/2023: thiamine 100 milligrams, 1 (one) tablet, orally, once daily - discontinue- effective 12/26/2023: pravastatin 20 milligrams, 1 (one) tablet, orally, once daily - discontinue- effective 12/26/2023: ferrous sulfate 325 milligrams, 1 (one) tablet, orally, once daily - discontinue- effective 12/26/2023: umeclidinium- vilanterol 62.5 micrograms- micrograms per inhalation, 1 (one) puff, inhaled, once daily Review of the Interdisciplinary Group Meeting dated 12/27/2023 lacks documented evidence of a discussion regarding the orders that were on 12/26/2023. During interview on 11/20/2024 at 09:54 AM, the Registered Nurse stated that hospice expectation is that verbal orders should be electronically signed immediately. The Registered Nurse further stated that being able to sign a verbal order immediately is unlikely, so the Registered Nurse tries to sign them as soon as possible, that documentation has always been a weak point, and that the Registered Nurses documentation tends to be late. At 09:56 AM, the Director of Patient Services stated that the hospice expectation is that verbal orders should be signed as soon as possible so those orders can be updated as soon as possible in the record. The Director of Patient Services further stated that orders cannot be added to the record until the clinician signs the order. That if the verbal order from 12/26/2024 was signed properly, the new orders would have been updated on the Interdisciplinary Group Meeting medication list on 12/27/2024. Patient #15- This 95-year-old patient with a terminal diagnosis of unspecified lump in unspecified breast was admitted to the hospice on 11/29/2023. Review of the Registered Nurse Visit Note dated 12/04/2023 revealed the Registered Nurse documented that the patient has developed significant lower extremity edema from the patients ankles the midcalf. The patient winced with assessment of the legs, estimate 3+ (three plus) edema at the ankles. The facility nurse will follow up with the physician related to restarting the patients hydrochlorothiazide, which had been stopped in September. The patient reportedly has had episodes of lower extremity edema since hydrochlorothiazide was discontinued. Review of the Hospice Plan of Care for 11/29/2023 to 02/26/2024 lacks an order for hydrochlorothiazide. Review of the clinical record lacks documented evidence the Registered Nurse communicated with the facility nurse or physician regarding the patients increased lower extremity edema. During interview on 11/202/2024 at 02:02 PM, the Director of Patient Services stated that the Registered nurse failed to obtain a proper order for hydrochlorothiazide.”

“Based on review of clinical record and interview with staff, for one (1) of nineteen (19) clinical records (Patient #11) the hospice failed to ensure ongoing sharing of information between all disciplines providing care. Failure to ensure the ongoing sharing of information has the potential for unmet patient needs. The hospice failed to ensure ongoing sharing of information between all disciplines providing care as evidenced by the following: Patient #11 – This 77-year-old patient with a terminal diagnosis of malignant neoplasm of the colon was admitted to the hospice on 09/26/2024. Review of the facility discharge summary dated 09/26/2024 revealed the patient had an exploratory laparotomy on 09/16/2024 for a colonic mass. Review of the Registered Nurse Routine Visit Note dated 10/02/2024 revealed the Registered Nurse documented the patient has a midline abdominal wound which is open to air with sutures. The patient is “going to the physician to have the sutures removed tomorrow (10/03/2024).” Review of the Registered Nurse Routine Visit Note dated 10/04/2024 lacks documentation whether the patients abdominal sutures were removed or any information regarding the 10/03/2024 medical appointment. During interview on 11/20/2024 at 11:16 AM, the Registered Nurse stated the patients sutures were removed at the 10/03/2024 medical appointment but the Registered Nurse did not document any follow-up regarding the appointment.”

“Based on review of clinical records and interviews with staff, for three (3) of four (4) patients (Patient #s: 1, 11, and 14) receiving aide services, the hospice failed to ensure the hospice aide Plan of Care was complete and accurate. Failure to ensure the Plan of Care is complete and accurate has the potential for the patient to receive inappropriate care. The hospice failed to ensure the hospice aide Plan of Care was complete and accurate as evidenced by the following: Patient #1 – This 83-year-old patient with a terminal diagnosis of Parkinsons disease without dyskinesia was admitted to the hospice on 10/11/2024. A. Review of the Registered Nurse Start of Care Visit Note dated 10/11/2024 revealed the patient has a sacral wound that is covered with allevyn dressing and a wound on the right heel. Review of the Aide Care Plan dated 10/22/2024 lacks instructions on how to keep the dressings dry and intact and to report when the integrity of the dressings are compromised. During interview on 11/20/2024 at 12:05 PM, the Registered Nurse stated she would update the aide plan of care to include instructions. B. Review of the Registered Nurse Visit Note dated 10/24/2024 revealed the Registered Nurse documented “;Foley catheter inserted today due to incontinence and large sacral ulcer.” Review of the Aide Care Plan dated 10/22/2024 lacks specific instructions regarding patients foley catheter and the tasks the aide is to perform regarding the foley catheter (i.e. emptying the bag, ensuring the foley is maintained below the level of the bladder, abnormalities that require nurse notification, etc.). During interview on 11/20/2024 at 12:05 PM, the Registered Nurse stated that aide plan of care would be updated to include instructions. Patient #14 – This 90-year-old patient with a terminal diagnosis of malignant neoplasm of prostate was admitted to the hospice on 08/14/2024. Review of the Registered Nurse Routine Visit Note dated 11/01/2024 revealed the Registered Nurse documented the following wound care for two new wounds: - left distal arm elbow/skin tear - cleansed with soap and water - covered with allevyn - right upper arm tricep/skin tear - cleansed with soap and water - covered with allevyn Review of the Aide Plan of Care dated 08/19/2024 lacks documented evidence the Registered Nurse updated the aide plan of care to include instructions on how to keep the dressings dry and intact and to report when the integrity of the dressings are compromised. During interview on 11/19/2024 at 03:44 PM, the Registered Nurse stated the aide plan of care was not updated to include pertinent information. The hospice failed to ensure the hospice aide Plan of Care was complete and accurate as evidenced by the following: Patient #11 – This 77-year-old patient with a terminal diagnosis of malignant neoplasm of the colon was admitted to the hospice on 09/26/2024. Review of the Registered Nurse Routine Visit Note dated 10/29/2024 revealed the patient has a right lower anterior leg skin tear that has a non-adherent dressing covered with a tegaderm dressing that is changed twice weekly by the Skilled Nurse. Review of the Aide Care Plan dated 10/31/2024 revealed the aide is assigned the task of assisting the patient with a bath or shower. The aide plan of care does not address how the aide is to keep the dressing dry an intact when bathing the patient or instructions to contact the Registered Nurse if the dressing is compromised. During interview on 11/20/2024 at 11:35 AM, the Registered Nurse stated the aide care plan fails to specify any instructions regarding the right lower leg dressing but should have been included.”

“Based on review of clinical records and interview with staff, for seventeen (17) of nineteen (19) clinical records (Patient #s: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 16, 17, 18, 19), the agency failed to provide documented evidence that a complete verbal or written certification of terminal illness was obtained by the Attending Physician and the Medical Director no later than two calendar days after hospice care is initiated. Failure to ensure the written certification of terminal illness is completed by the Attending Physician and the Medical Director has the potential for unmet patient needs. The agency failed to provide documented evidence that a complete verbal or written certification of terminal illness was obtained by the Attending Physician and the Medical Director no later than two calendar days after hospice care is initiated as evidenced by the following: Patient #11 – This 77-year-old patient with a terminal diagnosis of malignant neoplasm of the colon was admitted to the hospice on 09/26/2024. A.) Review of the Hospice Certification of Terminal Illness for the first 90-day period revealed the following: Terminal Diagnosis: Other specified disease of intestine. During interview on 11/19/2024 at 02:50 PM, the Supervising Public Health Nurse stated an incorrect diagnosis code was assigned to the Certification resulting in the error. B.) Review of the Hospice Certification of Terminal Illness for the first 90-day period lacks a brief narrative statement justifying the patient is terminally ill with a life expectancy of six months or less if the disease follows its normal course. C.) Review of the Hospice Certification of Terminal Illness for the first 90-day period revealed the following: - The Certification was electronically signed by the hospices Medical Director on 11/12/2024, forty-seven (47) days after the hospice election of benefits was completed. - The Certification was not signed by the Attending Physician. During interview on 11/19/2024 at 03:18 PM, the Supervising Public Health Nurse agreed the Hospice Certification of Terminal Illness is incomplete and not signed in accordance with regulation. Patient #12 – This 75-year-old patient with a terminal diagnosis of chronic obstructive pulmonary disease was admitted to the hospice on 09/25/2024. A.) Review of the Hospice Certification of Terminal Illness for the first 90-day period lacks a brief narrative statement justifying the patient is terminally ill with a life expectancy of six months or less if the disease follows its normal course. B.) Review of the Hospice Certification of Terminal Illness for the first 90-day period revealed the following: - The Certification was electronically signed by the hospices Medical Director on 11/12/2024, forty-eight (48) days after the hospice election of benefits was completed. - The Certification was not signed by the Attending Physician. During interview on 11/19/2024 at 02:37 PM, the Supervising Public Health Nurse agreed the Hospice Certification of Terminal Illness is incomplete and not signed in accordance with regulation. Patient #18 – This 66-year-old patient with a terminal diagnosis of malignant neoplasm of the endometrium was admitted to the hospice on 09/24/2024. A.) Review of the Hospice Certification of Terminal Illness for the first 90-day period revealed the Attending Physician documented “;the patient passed away on 10/07/2024” as the narrative statement justifying the patient is terminally ill with a life expectancy of six months or less if the disease follows its normal course. B.) Review of the Hospice Certification of Terminal Illness for the first 90-day period revealed the following: - the Certification was signed by the Attending Physician on 10/24/2024, thirty (30) days after the hospice election of benefits was completed and seventeen (17) days after the patient died. During interview on 11/19/2024 at 02:37 PM, the Supervising Public Health Nurse agreed the Hospice Certification of Terminal Illness is incomplete and not signed in accordance with regulation. Patient #19 – This 86-year-old patient residing in a skilled nursing facility with a terminal diagnosis of alzheimers disease, late onset was admitted to the hospice on 07/12/2024. Review of the Hospice Certification of Terminal Illness for the first 90-day period revealed the Certification was electronically signed by the hospices Medical Director on 07/16/2024, four (4) days after the hospice election of benefits was completed. During interview on 11/19/2024 at 02:37 PM, the Supervising Public Health Nurse stated the Hospice Certification of Terminal Illness is not signed in accordance with the regulation. Patient #10- This 95-year-old patient with a terminal diagnosis of hypertensive heart and chronic kidney disease with heart failure was admitted to the hospice on 10/03/2024. A. Review of the Hospice Certification of Terminal Illness for the first 90-day period lacks a brief narrative statement stating the patient is terminally ill with a life expectancy of six months or less if the disease follows its normal course. B. Review of the Hospice Certification of Terminal Illness for the first 90-day period revealed the following: - the Certification was not signed by the Attending Physician - the Certification was signed by the hospice’s Medical Director on 11/12/2024, forty (40) days after hospice care was initiated. During interview on 11/20/2024 at 02:06 PM, the Director of Patient Services stated that the Attending Physician signed a “;Certification of Terminal Illness” on the patients referral form with a brief statement, that the hospice documents the verbal certification from the Medical Director on the “;Determination of Eligibility” form, but no official order was written. Patient #16- This 74-year-old patient with a terminal diagnosis of amyotrophic lateral sclerosis was admitted to the hospice on 05/22/2024. A. Review of the Hospice Certification of Terminal Illness for the first 90-day period lacks a brief narrative statement stating the patient is terminally ill with a life expectancy of six months or less if the disease follows its normal course. B. Review of the Hospice Certification of Terminal Illness for the first 90-day period revealed the following: - the Certification was not signed by the Attending Physician - the Certification was signed by the hospice’s Medical Director on 06/11/2024, twenty (20) days after hospice care was initiated. During interview on 11/20/2024 at 03:12 PM, the Director of Patient Services stated that the hospice documents the verbal certification from the Medical Director on the “;Determination of Eligibility” form, but no official order was written, and that the hospice does not have a narrative statement signed by both physicians. The Director of Patient Services was also looking to see if a verbal certification was obtained from the Attending Physician. As of exit, no further documentation was provided. Patient #17- This 78-year-old patient with a terminal diagnosis of hypertensive heart and chronic kidney disease with heart failure was admitted to the hospice on 12/22/2023. Review of the Hospice Certification of Terminal Illness for the first 90-day period lacks a brief narrative statement stating the patient is terminally ill with a life expectancy of six months or less if the disease follows its normal course. During interview on 11/20/2024 at 12:51 PM, the Director of Patient Services stated that the only documented brief narrative statement was written and signed by the Attending Physician on the patients referral form, and there is no narrative statement on the Hospice Certification of Terminal Illness form. The agency failed to provide documented evidence that a complete verbal or written certification of terminal illness was obtained by the Attending Physician and the Medical Director no later than two calendar days after hospice care is initiated as evidenced by the following: Patient #1 – This 83-year-old patient with a terminal diagnosis of Parkinsons disease without dyskinesia was admitted to the hospice on 10/11/2024. A. Review of the Hospice Certification of Terminal Illness for 90-day period lacks a brief narrative statement stating the patient is terminally ill with a life expectancy of six months or less if the disease follows its normal course. B. Review of the Hospice Certification of Terminal Illness for the first 90-day period revealed the following: - the Certification was not signed by the hospice’s Medical Director - the Certification was signed by the Attending Physician on 10/15/2024, four days after hospice care was initiated. During interview on 11/19/2024 at 02:37 PM, the Supervising Public Health Nurse agreed the Hospice Certification of Terminal Illness is incomplete and not signed in accordance with regulation. Patient #2 -This 77-year-old patient with a terminal diagnosis of other sequela of cerebral infarction was admitted to the hospice on 11/01/2024. Review of the Hospice Certification of Terminal Illness for the first 90-day period revealed the Certification was signed by the Attending Physician on 11/06/2024, five days after hospice care was initiated. During interview on 11/19/2024 at 03:00 PM, the Supervising Public Health Nurse agreed the Hospice Certification of Terminal Illness is incomplete and not signed in accordance with regulation. Patient #3 – This 93-year-old patient with a terminal diagnosis of Alzheimers disease was admitted to the hospice on 11/07/2024. Review of the Hospice Certification of Terminal Illness for the first 90-day period revealed the following: - the Certification was not signed by the hospice’s Medical Director - the Certification was signed by the Attending Physician on 11/13/2024, six days after hospice care was initiated. During interview on 11/19/2024 at 12:18 PM, the Supervising Public Health Nurse stating the agency does get a verbal order from the Medical Director, but it was not documented and agreed the Attending Physician signed late. Patient #4 – This 58-year-old patient with a terminal diagnosis of acute respiratory failure was admitted to the hospice on 11/06/2024. Review of the Hospice Certification of Terminal Illness for the first 90-day period revealed the following: - the Certification was not signed by the hospice’s Medical Director - the Certification was signed by the Attending Physician on 11/13/2024, seven days after hospice care was initiated. During interview on 11/19/2024 at 03:18 PM, the Supervising Public Health Nurse agreed the Hospice Certification of Terminal Illness is incomplete and not signed in accordance with regulation. Patient #5 – This 74-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified part of left bronchus or lung was admitted to the hospice on 11/04/2024. Review of the clinical record lacks a Hospice Certification of Terminal Illness. During interview on 11/19/2024 at 03:27 PM, the Director of Patient Services stated she would look for it, no further information has been provided. Patient #6 – This 95-year-old patient with a terminal diagnosis of pathological fracture right femur sequela was admitted to the hospice on 11/01/2024. Review of the clinical record lacks a Hospice Certification of Terminal Illness. During interview on 11/19/2024 at 03:27 PM, the Director of Patient Services stated she would look for it, no further information has been provided. Patient #7 - This 98-year-old patient with a terminal diagnosis of congestive heart failure was admitted to the hospice on 10/25/2024. Review of the clinical record lacks a Hospice Certification of Terminal Illness. During interview on 11/19/2024 at 03:27 PM, the Director of Patient Services stated she would look for it, no further information has been provided. Patient #8 – This 34-year-old patient with a terminal diagnosis of malignant neoplasm of the rectum receiving inpatient hospice services at a local hospital was admitted to the hospice on 10/22/2024. Review of the Hospice Certification of Terminal Illness for the first 90-day period revealed the Certification was not signed by Medical Director. During interview on 11/19/2024 at 02:18 PM, the Supervising Public Health Nurse stating the agency does get a verbal order from the Medical Director, but it was not documented. Patient #9 – This 80-year-old patient with a terminal diagnosis of neurocognitive disorder with lewy bodies was admitted to the hospice on 10/21/2024. Review of the Hospice Certification of Terminal Illness for the first 90-day period revealed the Certification was signed by the Attending Physician on 10/29/2024, eight days after hospice care was initiated. During interview on 11/19/2024 at 12:35 PM, the Supervising Public Health Nurse agreed the Attending Physician signed late. Patient #14 – This 90-year-old patient with a terminal diagnosis of malignant neoplasm of prostate was admitted to the hospice on 08/14/2024. Review of the Hospice Certification of Terminal Illness for the first 90-day period revealed the Certification was signed by the Attending Physician on 09/11/2024, twenty-eight days after hospice care was initiated. During interview on 11/19/2024 at 03:35 PM, the Supervising Public Health Nurse agreed the Attending Physician signed late.”

“Based on review of clinical records and interview with agency staff, for eight (8) of nineteen (19) patients (Patient #s: 6, 10, 11, 13, 15, 16, 17, and 19) the hospice failed to ensure the clinical record contains correct clinical information. Failure to ensure that clinical records are complete and accurate has the potential for agency staff to act on inaccurate information and may place the patient’s health and welfare at risk. The hospice failed to ensure the clinical record contains correct clinical information as evidenced by the following: Patient #11 – This 77-year-old patient with a terminal diagnosis of malignant neoplasm of the colon was admitted to the hospice on 09/26/2024. A.) Review of the Registered Nurse Routine Visit Note dated 10/29/2024 revealed the Registered Nurse documented the following: - Dressing change completed to the right lower anterior leg skin care to include: washing area with soap and water, applying a non-adherent dressing and applying a tegaderm dressing. - Narrative: Leg dressing was removed and recommended the patient leave the skin tears open to air for the next several hours to help dry the skin tears out. The documentation in the 10/29/2024 visit is unclear if a dressing change was performed to the left leg skin tears or if the skin tears were left open to air. During interview on 11/20/2024 at 11:32 AM, the Registered Nurse stated the left lower leg skin tears were left open to air and no dressing change was performed to the left leg during the identified visit. B.) Review of the Registered Nurse Routine with Supervisory Visit Note dated 10/31/2024 revealed the visit was conducted on 10/31/2024, but was signed and the documentation completed on 11/11/2024, eleven (11) days after the visit. During interview on 11/19/2024 at 10:09 AM, the Director of Patient Services stated it is the agency expectation that all documentation be completed within seven (7) days of the visit date. During interview on 11/20/2024 at 11:36 AM, the Registered Nurse stated being very busy and prioritizes patient care over completing documentation on time. Patient #19 – This 86-year-old patient residing in a skilled nursing facility with a terminal diagnosis of alzheimers disease, late onset was admitted to the hospice on 07/12/2024. A.) Review of the Registered Nurse Routine Visit Note dated 07/16/2024 revealed the Registered Nurse documented the patient has a left lower posterior heel pressure ulcer stage 2 (two). Additionally, the Registered Nurse documented the same wound is unstageable. The documentation is unclear if the patient has a stage 2 (two) pressure ulcer or an unstageable wound to the left heel. During interview on 11/20/2024 at 10:12 AM, the Registered Nurse stated the left heel ulcer was unstageable in the identified visit. During interview on 11/20/2024 at 10:20 AM the Director of Patient Services stated the Registered Nurse completed the 07/16/2024 documentation incorrectly. The Director of Patient Services stated the stage 2 (two) pressure wound documentation should have been end dated and physician notification with initiation of a unstageable wound assessment should have been documented in the identified visit. B.) Review of the Medical Social Worker Assessment Note dated 07/16/2024 revealed the visit was conducted on 07/16/2024, but was signed and the documentation completed on 07/31/2024, fifteen (15) days after the visit. During interview on 11/19/2024 at 03:19 PM, the Director of Patient Services stated the clinicians documentation was completed late and it is the agency expectation that all documentation be completed within seven (7) days of the visit date. Patient #16- This 74-year-old patient with a terminal diagnosis of amyotrophic lateral sclerosis was admitted to the hospice on 05/22/2024. A. Review of the Home Health Aide Visit Note dated 05/28/2024 revealed the visit was conducted on 05/28/2024, but signed 06/07/2024, 10 (ten) days after the visit. B. Review of the Home Health Aide Visit Note dated 05/30/2024 revealed the visit was conducted on 05/30/2024, but signed 06/07/2024, 8 (eight) days after the visit. During interview on 11/20/2024 at 03:00 PM, the Supervising Public Health Nurse stated it is unusual for that Home Health Aide to document late, the Public Health Supervising Nurse was unable to recall any issues at that time, so the documentation should have been completed on time. C. Review of the Registered Nurse Visit Note dated 05/30/2024 revealed the visit was conducted on 05/30/2024, but signed 06/13/2024, 14 (fourteen) days after the visit. D. Review of the Registered Nurse Visit Note dated 06/04/2024 revealed the visit was conducted on 06/04/2024, but signed 06/23/2024, 19 (nineteen) days after the visit. During interview on 11/20/2024 at 11:40 AM, the Registered Nurse stated that visit notes should be completed within 7 (seven) days of the visit. E. Review of the Licensed Master Social Worker Visit Note dated 06/04/2024 revealed a phone call with the patients family was conducted on 06/04/2024, but signed 06/18/2024, 14 (fourteen) days after the call. During interview on 11/19/2024 at 01:55 PM, the Licensed Master Social Worker stated, “;This was an intense call both in length and information discussed, but it should have been documented within 7 (seven) days.” Patient #15- This 95-year-old patient with a terminal diagnosis of unspecified lump in unspecified breast was admitted to the hospice on 11/29/2023. A. Review of the Licensed Master Social Worker Visit Note dated 11/30/2023 revealed the visit was conducted on 11/30/2023, but signed 12/08/2023, 8 (eight) days after the visit. B. Review of the Licensed Master Social Worker Visit Note dated 12/08/2023 revealed the visit was conducted on 12/08/2023, but signed 12/19/2023, 11 (eleven) days after the visit. During interview on 11/19/2024 at 02:16 PM, the Licensed Master Social Worker stated that these notes were signed late, and should have been done within 7 (seven) days. Patient #17- This 78-year-old patient with a terminal diagnosis of hypertensive heart and chronic kidney disease with heart failure was admitted to the hospice on 12/22/2023. A. Review of the Registered Nurse Visit Note dated 12/26/2023 revealed the visit was conducted on 12/26/2023, but signed 01/05/2024, 10 (ten) days after the visit. During interview on 11/20/2024 at 09:59 AM, the Registered Nurse stated, “;I do the best I can, but patient care takes precedence over documentation, so I often document late unfortunately.” B. Review of the Licensed Master Social Worker Visit Note dated 12/26/2023 revealed the visit was conducted on 12/26/2023, but signed 01/08/2024, 12 (twelve) days after the visit. During interview on 11/19/2024 at 01:41 PM, the Licensed Master Social Worker stated that there is no excuse, but the delayed documentation was probably due to the holiday. Patient #10- This 95-year-old patient with a terminal diagnosis of hypertensive heart and chronic kidney disease with heart failure was admitted to the hospice on 10/03/2024. Review of the Registered Nurse Visit Note dated 10/15/2024 revealed the visit was conducted on 10/15/2024, but signed 11/04/2024, 20 (twenty) days after the visit. During interview on 11/20/2024 at 10:59 AM, the Registered Nurse stated that this note was signed late, and should be done within 7 (seven) days. The hospice failed to ensure the clinical record contains correct clinical information as evidenced by the following: Patient #6 – This 95-year-old patient with a terminal diagnosis of pathological fracture right femur sequela was admitted to the hospice on 11/01/2024. Review of the Hospice Plan of Care for 11/01/2024 to 01/29/2025 revealed the order to “;Remove surgical dressing twice a week or as needed. Gently cleanse with wound spray, pat dry and cover with ABD pads and secure with tape” for surgical wounds right upper leg and thigh. Review of the Registered Nurse Start of Care Visit Note dated 11/01/2024 revealed the Registered Nurse documented the following: Incision Care: see orders. The Registered Nurse failed to document what wound care was provided. Review of the Registered Nurse Routine Visit Note dated 11/04/2024 revealed the Registered Nurse documented the following: Incision Care: wash and change dressing. The Registered Nurse failed to document what wound care was provided. Review of the Registered Nurse Routine Visit Note dated 11/07/2024 revealed the Registered Nurse documented the following: Incision Care: clean with wound spray two times a week with dressing change or as needed. The Registered Nurse failed to document what wound care was provided. During interview on 11/20/2024 at 10:30 AM, the Registered Nurse stated the dressing change was done in accordance with physician orders, but they failed to document what wound care was performed during the visits. Patient #13 – This 61-year-old patient with a terminal diagnosis of malignant neoplasm of appendix was admitted to the hospice on 09/19/2024. Review of the Medical Social Worker Visit Note dated 10/07/2024 revealed the visit was conducted on 10/07/2024, but signed 10/16/2024, nine days after the visit. During interview on 11/20/2024 at 01:38 PM, the Licensed Medical Social Worker stated the expectation for signing notes is within seven days, this note was signed late.”

“Based on clinical record review and staff interviews, for two (2) of nineteen (19) patients, (Patient #s: 11 and 13) the hospice failed to ensure patient records include completed notices of patient rights and election statements. Failure to ensure clinical records contain completed notice of patient rights and election statement has the potential for unmet patient needs. The hospice failed to ensure clinical records include completed copies of the notice of patient rights and election statements is evidenced by the following: Patient #13 – This 61-year-old patient with a terminal diagnosis of malignant neoplasm of appendix was admitted to the hospice on 09/19/2024. Review of the Hospice Benefit Election Form signed 09/19/2024 revealed the following: “3. I understand these services will be provided according to an assessment of my needs by the Hospice Interdisciplinary Group, approved by (blank) that I have designated as my attending physician, and specified in the Hospice Plan of Care.” The form is incomplete and does not include the name of the designated attending physician. During interview on 11/19/2024 at 03:35 PM, the Director of Patient Services stated the form should not have any blanks. The hospice failed to ensure clinical records include completed copies of the notice of patient rights and election statements is evidenced by the following: Patient #11 – This 77-year-old patient with a terminal diagnosis of malignant neoplasm of the colon was admitted to the hospice on 09/26/2024. Review of the Hospice Benefit Election Statement for Medicare revealed the following; - The patient signed the election form but no date is documented. - The Registered Nurse signed and dated the election form as the witness on 09/26/2024. During interview on 11/20/2024 at 12:23 PM, the Registered Nurse stated the election form was not reviewed when it was signed, and it was not confirmed that the form was complete.”

“Based on review of clinical records and interviews with staff, for two (2) of nineteen (19) patients (Patient #’s: 11 and 19), the hospice failed to ensure orders are complete and accurately documented in the clinical record. Failure to ensure the Plan of Care is accurate and reflects the patients needs has the potential to result in inappropriate care, unmet patient needs, and negative patient outcomes. The hospice failed to ensure orders are complete and accurately documented as evidenced by the following: Patient #11 – This 77-year-old patient with a terminal diagnosis of malignant neoplasm of the colon was admitted to the hospice on 09/26/2024. Review of the Patient Care Order (Verbal Order) dated 10/29/2024 revealed the Registered Nurse documented the following order: “Wash with warm water and soap as tolerated. Cover with xeroform and tegaderm twice a week and as needed until healed.” The order is incomplete and does not include the location of the wound to be treated. During interview on 11/20/2024 at 11:33 AM, the Registered Nurse stated the patient has two skin tears to the left lower leg that required the wound care, but the wound/treatment locations were not included in the order. Patient #19 – This 86-year-old patient residing in a skilled nursing facility with a terminal diagnosis of alzheimers disease, late onset was admitted to the hospice on 07/12/2024. Review of the Patient Care Order (Verbal Order) dated 07/24/2024 revealed the Registered Nurse documented the following order: - morphine 20 milligrams per 5 milliliter oral solution, administer 15 milligrams oral every one (1) hour as needed for pain, shortness of breath; and - morphine 20 milligrams per 5 milliliter oral solution, administer 15 milligrams oral every four (4) hours as needed for pain, shortness of breath. It is unknown whether the medication should be administered every one hour or every four hours for pain or shortness of breath or whether administration of the medication should be based on the intensity of symptoms. During interview on 11/20/2024 at 12:43 PM, the Director of Patient Services stated the Registered Nurse that wrote the order was unavailable for interview. The Director of Patient Services stated the morphine order to administer every four (4) hours as needed was encompassed within the morphine order to administer every one (1) hour as needed and should not have been written the way it was.”

“Based on review of clinical records and interviews with agency staff, the agency failed for two (2) of nineteen (19) patients (Patient #s: 10 and 17) to ensure all documentation by professional staff is appropriately authenticated in accordance with accepted standards of practice. Failure to authenticate documentation has the potential for patients to receive care from unlicensed staff. The hospice failed to authenticate physicians signatures and titles as evidenced by the following: Patient #10- This 95-year-old patient with a terminal diagnosis of hypertensive heart and chronic kidney disease with heart failure was admitted to the hospice on 10/03/2024. Review of the “;Referral for Hospice Services” form dated 10/01/2024 revealed the Attending Physician documented a certification of terminal illness and signed the document on 09/30/2024 but the signature and title are illegible. During interview on 11/20/2024 at 10:36 AM, the Registered Nurse stated that the Attending Physician signed the certification of terminal illness on the referral, but the Registered Nurse was unable to determine if the signature included credentials. Also, at 10:36 AM, the Director of Patient Services stated that the hospice does not have a physician signature log and was unable to read the signature on the referral. Patient #17- This 78-year-old patient with a terminal diagnosis of hypertensive heart and chronic kidney disease with heart failure was admitted to the hospice on 12/22/2023. Review of the “;Referral for Hospice Services” form dated 12/22/2023revealed the Attending Physician documented a certification of terminal illness and signed the document on 12/21/2023 but the signature and title are illegible. During interview on 11/20/2024 at 12:47 PM, the Director of Patient Services stated that the signature is illegible and is missing a title, in addition the Director of Patient Services stated that the hospice does not have a physician signature log to authenticate signatures.”

“Based on clinical record review and staff interview the hospice failed to ensure a comprehensive discharge summary was prepared that contained all required components for two (2) of five (5) patients discharged to the community (Patient #s: 15 and 16). Failure to prepare a comprehensive discharge summary places patients at risk for poor coordination of patient services and unmet patient needs upon discharge/transfer from the hospice. The agency failed to document a complete agency discharge summary and communicate with all disciplines involved in the patients care including the physician as evidenced by the following: Patient #15- This 95-year-old patient with a terminal diagnosis of unspecified lump in unspecified breast was admitted to the hospice on 11/29/2023. This patient resides in an Adult Home. Review of the Registered Nurse Visit Note dated 12/14/2023 revealed the patient was injured at the Adult Home and needed hospital care to address the injury. The Registered Nurse documented that the patient would be discharged from hospice to receive care at the hospital on 12/14/2024. Review of the clinical record lacks documented evidence of signed hospice revocation form, evidence the physician was notified of the discharge, and a discharge summary. Additionally, there is no evidence the hospital was provided with a discharge summary. During interview on 11/20/2024 at 02:07 PM, the Director of Patient Services stated that the clinical record lacks documentation that the physician was notified, no discharge orders were obtained, and no discharge summary was sent to the physician. Patient #16- This 74-year-old patient with a terminal diagnosis of amyotrophic lateral sclerosis was admitted to the hospice on 05/22/2024. Review of the Registered Nurse Visit Note dated 06/05/2024 revealed the patient was discharged from hospice to have an elective surgery for a gastric tube change on 06/05/2024. Review of the clinical record lacks documented evidence the physician was updated of the patients discharge and no discharge orders were obtained. The clinical records also lacks evidence that a discharge summary was sent to the physician. During interview on 11/20/2024 at 11:43 AM, the Registered Nurse stated that the physician was aware of the discharge but that is not documented. The Registered Nurse was unable to remember if discharge orders were obtained, and that a discharge summary was likely not completed due to the planned re-admission of the patient to hospice services after the gastric tube procedure was completed.”

“Based on review of clinical records and interviews with staff, for one (1) of five (5) patients receiving care in a Skilled Nursing Facility (Patient #19), the hospice failed to coordinate and implement a plan of care with interventions that reflect the needs of the patient and that are consistent with the SNF plan of care (POC). Failure to communicate, coordinate and provide professional management of hospice patients that reside in a SNF has the potential for the provision of inadequate patient care and unmet patient needs. The hospice nurse failed to communicate, coordinate and provide professional management of hospice patients residing in a Skilled Nursing Facility as evidenced by the following: Patient #19 – This 86-year-old patient residing in a skilled nursing facility with a terminal diagnosis of alzheimers disease, late onset was admitted to the hospice on 07/12/2024. Review of the Medication List included with the skilled nursing facility referral for hospice dated 07/09/2024 revealed the following orders: - lantus solostar unit-100 insulin, 100 units per milliliter, give 10 units subcutaneous once a day; - santyl 250 unit per gram ointment, apply light coating topical once a day to left heel wound and cover with dry sterile dressing. Review of the Registered Nurse Start of Care Visit Note dated 07/12/2024 revealed the Registered Nurse documented the following: - Left lower posterior medial distal outer foot heel decubitus pressure ulcer stage 2 (two): Wound not seen this visit; - Patient with dementia and does not understand illness and disease process; - Son is patients primary caregiver and is aware and understanding of disease process; - Blood glucose monitoring occurs before meals and patient is unable to self test; - Medication profile review: Medications reconciled and no issues identified; - Patient is total care and totally dependent on others; and - Contacts made as a result of this visit: Physician, Supervisor, Primary Nurse, and Medical Social Worker. The assessment lacks documentation of coordination of the patients care with the skilled nursing facility staff to develop the plan of care. Review of the Hospice Plan of Care for 07/12/2024 to 10/09/2024 lacks documented evidence of the following: - Orders for wound care to the left heel and specification if the skilled nursing facility completes the wound care or the hospice; - Orders for blood glucose monitoring, frequency, blood glucose parameters to notify the physician for, diabetic supplies and if the skilled nursing facility staff manages all diabetic care; - Orders for a hospice aide or specification of what care the skilled nursing facility provides for the dependent patient. During interview on 11/20/2024 at 11:20 AM, the Registered Nurse stated the staff at the skilled nursing facility were consulted regarding the patients care orders during the admission assessment, but it was not documented.”