Hospice of New York, LLC

“Based on clinical record review and staff interview, the hospice failed to ensure the Interdisciplinary Group (IDG) reviewed and revised the individualized Plan of Care (POC) as the patient’s care needs change, but no less frequently than every fifteen (15) days. This was evident for one (1) of three (3) clinical records reviewed (Patient #3). Failure of the Interdisciplinary Group to develop, review, and revise the Plan of Care has the potential for negative patient outcomes. The findings are: 1.Patient #3 has a Start of Care date of 08/06/2025 with the following diagnoses “Malignant Neoplasm of Retroperitoneum, Essential (Primary) Hypertension, Gastro-Esophageal Reflux Disease without Esophagitis” documented on the Physician’s Orders/Plan of Care effective 08/06/2025 for the Certification of Terminal Illness Period from 008/06/2025 to 11/03/2025.The Clinical Record documents IDG (Interdisciplinary Group) on 08/07/2025 and following on 08/28/2025.There is no documented evidence of the IDG (Interdisciplinary Group) reviewing and revising the patient’s individualized plan of care at least every 15 days or as needed.On 11/06/2025 at 04:30 PM, the Clinical Director was interviewed and stated: “IDG was missed. Human error. Leadership is now aware of this possible oversight and will amend our process to ensure this does not reoccur.””

“Based on clinical record review and staff interview the Hospice failed to ensure all patients and their authorized caregivers has the right to refuse care or treatment. This was evident for one of six (6) clinical records reviewed. (Patient #1). Failure to ensure patients and authorized caregivers has the right to refuse care or treatment has the potential for negative patient outcome. 1. Patient #1 has a Start of Care date of 07/22/2024 with the following diagnoses “Unspecified Sequelae of Cerebral Infarction, Chronic Obstructive Pulmonary Disease” documented in the Physicians Orders/Plan of Care for the Certification Period 07/22/2024 to 10/19/2024. The Charts/Clinical Notes documents: 07/25/2024 “;received telephone call from patients daughter (name) asking the purpose of Hospice and does not wish to have patients possible pneumonia treated, hospice plan of care and comfort measures discussed.” 07/30/2024 “;reported PCG (patient caregiver) refused use of Antibiotic for URI (upper respiratory infection) as recommended by PMD (primary medical doctor).” 08/06/2024 “;PCG (patient caregiver) does not want any aggressive treatments, no antibiotics. Pain medications, comfort measures only.” The Complaint Investigation Form dated 11/22/2024 documents (text message on 07/26/2024, printed as part of the investigation): (Name of doctor) and I spoke regarding what is best for my mother and what she would have wanted. Giving my mother antibiotics is not going to make my mother better. It is not going to make my mother better.” “Nothing we do will give my mother back the life she had or the life she wanted. Giving my mother antibiotics to treat pneumonia is not going to save her, it is only going to drag this out longer for my mom. I do NOT want any intervention to treat ANYTHING. I want my mother to be comfortable so that her passing is as peaceful and dignified as possible. This decision was not easy to make. (Name of doctor) advised me to do nothing and to let her pass. That her COPD (Chronic Obstructive Pulmonary Disease) is in the final stages and that nothing we do is going to help return her back to what she would have wanted for her life.” The Order Recap Report (from the Assisted Living Facility) documents order date on: 07/26/2024 Augmentin Oral Tablet 500-125 mg (milligram) Give 1 tablet by mouth two times a day for URI/PNA (upper respiratory infection/ pneumonia) for 7 days.08/02/2024 Amoxicillin Pot Clavulanate Tablet 500-125 mg (milligram) Give 1 tablet by mouth two times a day for URI/PNA (upper respiratory infection/ pneumonia) for 7 days. The clinical record lacks documented evidence that the familys request of no antibiotic was being followed. There is no documented evidence the patients right to refuse treatment is being exercised. On 01/03/2025 at 9:30AM, Administrator, the Clinical Director, the Executive Director of QAPI (Quality Assurance and Performance Improvement) and the other staff were interviewed and did not provide an explanation for the findings.”

“Based on clinical record review and staff interview the hospice failed to ensure a process is established where the facility can exchange information with the IDG regarding the plan of care, review and update assessments, conference with the hospice and the facility team to ensure the patient receives the necessary care and services and all changes are authorized by the hospice. This was evident for one (1) of six (6) clinical records reviewed. (Patient #1). Failure to ensure a process is established where the facility can exchange information with the IDG regarding the plan of care, review and update assessments, conference with the hospice and the facility team regarding all necessary care and services prior to changes being made has the potential for negative patient outcome. The findings are: 1. Patient #1 has a Start of Care date of 07/22/2024 with the following diagnoses “Unspecified Sequelae of Cerebral Infarction, Chronic Obstructive Pulmonary Disease” documented in the Physicians Orders/Plan of Care for the Certification Period 07/22/2024 to 10/19/2024. The Supplemental Orders documents: 07/25/2024 “;Dakins External Solution Clean wounds (right and left Ischium and Sacrum) with wound wash pat dry and apply Dakins soaked gauze and cover with bordered gauze daily.”10/29/2024 “;Curity Iodoform Packing Strip, 1 strip to right and left ischium three times a week, other days done by facility staff.”11/29/2024 (discontinue order) “;Dakins External Solution Clean wounds (right and left Ischium and Sacrum) with wound wash pat dry and apply Dakins soaked gauze and cover with bordered gauze daily ended on 11/29/2024.” The Order Recap Report from ALF (Assisted Living Facility) documents order date on: 07/25/2024 HONY (Hospice of New York) to provide wound care to left ischium as follow: Cleanse left ischial pressure injury with NS (normal saline), apply Santyl, pack with alginate and cover with foam dressing daily. Discontinued 10/30/2024. 10/30/2024 HONY (Hospice of New York) to provide wound care to left ischium as follow: Cleanse left ischial pressure injury with NS (normal saline), Iodoform ribbon cover with dry dressing daily. 07/25/2024 HONY (Hospice of New York) to provide wound care to right ischium as follow: Cleanse right ischium pressure injury with NS (normal saline), apply Santyl, then alginate and cover with border foam dressing daily. Discontinued 10/30/2024. 07/25/2024 HONY (Hospice of New York) to provide wound care to sacral pressure injury as follow: Cleanse sacral pressure injury with NS (normal saline), apply Santyl to wound bed, then alginate and cover with border foam dressing daily. Discontinued 08/06/2024. 08/06/2024 HONY (Hospice of New York) to provide wound care to sacral pressure injury as follow: Cleanse sacral pressure injury with NS (normal saline), apply Dakins on a 2x2 to wound bed, and cover with border foam dressing daily. Discontinued 10/30/2024. 10/30/2024 HONY (Hospice of New York) to provide wound care to sacrum and right ischium pressure injury as follow: Cleanse with NS (normal saline), apply Iodoform ribbon with border dressing daily. Discontinued 11/22/2024. 07/26/2024 Augmentin Oral Tablet 500-125 mg (milligram) Give 1 tablet by mouth two times a day for URI/PNA (upper respiratory infection/ pneumonia) for 7 days. 08/02/2024 Amoxicillin Pot Clavulanate Tablet 500-125 mg (milligram) Give 1 tablet by mouth two times a day for URI/PNA (upper respiratory infection/ pneumonia) for 7 days. The clinical record lacks documented evidence of the discussion between the hospice and the facility regarding changes in the wound treatment and orders for antibiotics (not on hospice plan of care). There is no documented evidence of the discussion with the hospice and the facility regarding changes in the hospice plan of care and the approval by the hospice before implementation. On 01/03/2025 at 9:30AM, Administrator, the Clinical Director, the Executive Director of QAPI (Quality Assurance and Performance Improvement) and the other staff were interviewed and did not provide an explanation for the findings.”

“Based on clinical record review, and staff interview, the hospice failed to ensure the content of the comprehensive assessment is complete and of sufficient scope to identify all the patient’s needs to promote the overall well-being of the patient throughout the dying process. This was evident for five (5) of twenty-nine (29) clinical records reviewed. (Patient #2,5,7,22,23) Failure to ensure the comprehensive assessment is complete and includes all necessary information to meet the patient needs and promote the well-being, comfort, and dignity throughout the dying process has the potential for negative outcome. The findings are: 4.Patient #22 has a Start of Care date of 8/11/2024 with diagnoses of Malignant Neoplasm of unspecified part of unspecified bronchus or lung, and Unspecified Sequelae of unspecified Cerebrovascular disease documented on the Physicians Orders/Plan of Care with a Certification Period from 8/11/2024 to 11/8/2024. The RN (Registered Nurse) routine visit “;Charts/Clinical Notes” with an “Effective Date: 8/14/24” documents, “;. . .. Patient complains about pain in the lower extremities. Patient is on gabapentin and takes morphine RDT (Rapid Dissolving Tablet) from comfort care kit. RN asked for the level of the pain in scale of 1-10 (1 being the lowest level of pain, and 10 being the highest level of pain), and patient answered the level of 10. RN contacted NP (name of Nurse Practitioner) collaborated about medications. (Name of NP) recommend Hydromorphone HCL (Hydrochloride) 2 mg (milligrams) tablet take 1 table every 3 hours as needed, and Methadone HCL 5 mg tablet take ½ tablet every 12 hours for pain management. RN review the medications with patient and PCG (Patient Caregiver), and they verbalized understanding . . .” The next documented RN visit was 8/20/2024. The RN (Registered Nurse) routine visit “;Charts/Clinical Notes” dated 8/20/24 documents, “;. . .. Patient continues to take Hydromorphone, and Methadone with good result . . .” There is no documented evidence of the RN re-assessing the effectiveness of the recommended pain management regimen until six (6) days later on 8/20/2024, after the patient reported having a pain level of 10 (the highest level of pain) on 8/14/24. On 10/04/2024 at 01:07 PM, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 5.Patient #23 has a Start of Care date of 5/30/2024 with diagnoses of Cerebrovascular disease, unspecified and Vascular dementia documented on the Physicians Orders/Plan of Care with a Certification Period from 5/30/2024 to 8/27/2024. The Initial RN (Registered Nurse) comprehensive visit was conducted on 5/30/2024. The “;Charts/Clinical Notes” with an “Effective Dates: 5/30/24” documents, “;Patient has skin tear on right shin and sacral (Pressure Ulcer). (wound in the skin and tissue that occurs when pressure is applied to the same area of skin for a long time). The Initial comprehensive assessment lacks documented evidence of the appearance, size, and type of treatment for the sacral pressure ulcer. The RN “;Charts/Clinical Notes” with an “;Effective Date: 8/6/24” documents, “;Patient has a venous ulcer that is not healing and was present upon admission.” There is no documented evidence of the patient having a venous ulcer (an open sore that develops on the leg when the veins aren’t working properly to pump blood back to the heart) upon admission in the Initial comprehensive assessment dated 5/30/2024. On 10/03/2024 at 01:05 PM and 10/04/2024 at 01:07 PM, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. The wound Care Nursing Protocol and Documentation Guidelines documents: The Hospice RN (registered nurse) will assess wounds at least once each week.Documentation of the wound is in the Skin/Evaluation section of the assessment in incision/wound tab includes: wound measurement. 1. Patient #2 has a Start of Care date of 07/26/2024 with the following diagnoses “Senile Degeneration of Brain, Dementia” documented in the Physicians Orders/ Plan of Care for the Certification Period 07/26/2024 to 10/23/2024. The Initial Visit (comprehensive assessment) dated 07/26/2024 documents: Sacrum, pressure ulcer, Stage 3,(full thickness tissue loss that extends into the deeper tissue and fat, but doesn’t expose bone, tendon, or muscle) not measured, beefy red. The Team Care Plan as of 10/01/2024 documents: Alteration in skin integrity, Intervention: measure and stage wound PRN (as needed) Stage 3 sacrum PU (pressure ulcer) (full thickness tissue loss that extends into the deeper tissue and fat, but doesn’t expose bone, tendon, or muscle). The comprehensive assessment lacks documented evidence of the measurement of the sacrum pressure ulcer. On 10/03/2024 at 01:05 PM, the Administrator/ CEO (Chief Executive Officer), The Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, the Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 2. Patient #5 has a Start of Care date of 08/22/2024 with the following diagnoses “End Stage Renal Disease, Unspecified Dementia with Anxiety” documented in the Physicians Orders/ Plan of Care as of 08/22/2024, for the Certification of Terminal Illness Period 08/22/2024 to 10/20/2024. The Initial Visit (comprehensive assessment) dated 08/22/2024 documents: Redness to Sacrum; Instructed on: pressure relief measures, incontinent management. The comprehensive assessment lacks documented evidence of the accurate wound description – is this a pressure ulcer / non-blanchable redness, measurement, and treatment. On 10/03/2024 at 01:05 PM the Administrator/ CEO (Chief Executive Officer), The Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, the Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 3. Patient #7 has a Start of Care date of 06/12/2024 with the following diagnoses “Dementia, Pressure Ulcer of Right Hip Stage 4, Pressure Ulcer of Left Hip Stage 4” documented in the Physicians Orders/ Plan of Care for the Certification Period 06/12/2024 to 09/04/2024. The Initial Visit (comprehensive assessment) dated 06/12/2024 documents: Left Hip, pressure ulcer, Stage 4(full-thickness tissue loss with exposed bone, tendon, or muscle) not measured, beefy red, Epithelial, Slough 1%, Granulation 99%.Right Hip, pressure ulcer, Stage 4 (full-thickness tissue loss with exposed bone, tendon, or muscle) not measured, pink, beefy red, granulation 100%. Lower Right Hip, pressure ulcer, Unstageable (a wound that is either a stage 3 or 4 pressure ulcer, but is covered by slough or eschar, making it impossible to determine stage), not measured, Eschar 100%. The comprehensive assessment lacks documented evidence of the measurement of the pressure ulcers. On 10/03/2024 at 01:05 PM, the Administrator/ CEO (Chief Executive Officer), The Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, the Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings.”

“Based on clinical record review and staff interview, the agency failed to ensure all comprehensive assessments includes all current medication. This was evident for one (1) of twenty-nine (29) clinical records reviewed (Patient #1). Failure to ensure all comprehensive assessments include all current medication, has potential for negative patient outcome. The findings are: 1.Patient #1 has a Start of Care date of 01/16/2024 with the following diagnoses “Senile Degeneration of Brain, Dementia” documented in the Physicians Orders/ Plan of Care as of 09/12/2024, for the Certification of Terminal Illness Period 09/12/2024 to 11/10/2024 The Physicians Orders/ Plan of Care as of 09/12/2024 documents: Temperature elevation: Acetaminophen 325-650 mg (milligram) po (by mouth). The Medication List dated 09/30/2024 and the Visit Record dated 09/17/2024, 09/23/2024, 09/24/2024, 09/26/2024, and 09/30/2024 lacks documented evidence of Acetaminophen 325-650 milligram by mouth. There is no documented evidence of a review of all medications. On 10/03/2024 at 01:05PM, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings.”

“Based on clinical record review, and staff interview, the Hospice failed to ensure the Interdisciplinary Group (IDG) members are performing complete and updated comprehensive assessments, to include changes that have taken place since the initial assessment, the patient’s progress toward desired outcomes as frequently as the condition of the patient requires, but no less frequently than every 15 days. This was evident for eight (8) of twenty-nine clinical records reviewed. (Patient #1, #2, #3, #4, #5, #6, #7, #18). Failure to ensure that comprehensive assessments are updated and reflect changes in the status, and the patients progress has the potential for negative patient outcome. The findings are: 8. Patient #18 has a Start of Care date of 08/30/2024 with diagnoses of Unspecified dementia, unspecified severity, without behavior disturbance, psychotic disturbance, mood disturbance, and anxiety documented on the Physician’s Order/ Plan of Care as of 08/30/2024. The Hospice RN (Registered Nurse) Initial Visit dated 08/30/2024 documents: “;Physical/Skin/Evaluation: Skin: Skin Integrity: Intact.” The Team Care Plan dated 08/30/2024 documents: “;Skin integrity maintained. Interventions: Assess skin integrity q (every) visit, Instruct CG (caregiver) in proper positioning, monitor skin changes due to disease process, Instruct CG re potential for skin breakdown, Identify risks for skin breakdown.” The Routine Visit documents: 09/06/2024, 09/13/2024 Physical/Skin/Incision/Wound: Upper Back: Site Location: Upper Back; Type: Skin Tear; Healing: Healing by secondary intent; Wound Measurement: Not measured; Incision, wound tissue observed: Pink; Dressing Changed this visit: Yes, per orders, see care Plan. 9/17/2024 Physical/Skin/Incision/Wound: Left Heel: Site Location: Specify location: left heel; Type: blister; Healing: Not healing; Wound Measurement: Not measured; Incision/Wound Tissue Observed: Pink, Beefy red; Dressing Changed this visit: Yes, per orders, see care Plan. The clinical record lacks documented evidence of an updated comprehensive assessment that includes wound measurement, patients progress toward desired outcomes, and response to care every 15 days. On 10/03/2024 at 01:05PM, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 1. Patient #1 has a Start of Care date of 01/16/2024 with the following diagnoses “Senile Degeneration of Brain, Dementia” documented in the Physicians Orders/ Plan of Care as of 09/12/2024, for the Certification of Terminal Illness Period 09/12/2024 to 11/10/2024. The clinical record documents routine nurse visits on 09/17/2024, 09/23/2024, and 09/30/2024. The clinical record lacks documented evidence of an updated comprehensive assessment that includes patients progress toward desired outcomes, and response to care every 15 days. On 10/03/2024 at 01:05PM, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 2. Patient #2 has a Start of Care date of 07/26/2024 with the following diagnoses “Senile Degeneration of Brain, Dementia” documented in the Physicians Orders/ Plan of Care for the Certification Period 07/26/2024 to 10/23/2024. The Initial Visit (comprehensive assessment) dated 07/26/2024 documents: Sacrum, pressure ulcer, Stage 3, (full thickness tissue loss that extends into the deeper tissue and fat, but doesn’t expose bone, tendon, or muscle) not measured, beefy red. The Team Care Plan as of 10/01/2024 documents: Alteration in skin integrity, Intervention: measure and stage wound PRN (as needed) Stage 3 sacrum PU (pressure ulcer). The Routine Visit documents: 07/29/2024, 08/06/2024 Sacrum, pressure ulcer, Stage 3, not measured, Pink, slough 50%.08/13/2024, 08/20/2024, 08/27/2024 Sacrum, pressure ulcer, Stage 3, not measured, Pink.09/10/2024, 09/19/2024, 09/26/2024 Sacrum, pressure ulcer, Stage 2, not measured, Pink. The clinical record lacks documented evidence of an updated comprehensive assessment that includes wound measurement, patients progress toward desired outcomes, and response to care every 15 days. On 10/03/2024 at 01:05PM, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 3. Patient #3 has a Start of Care date of 10/14/2023 with the following diagnoses “Senile Degeneration of Brain, Dementia” documented in the Physicians Orders/ Plan of Care as of 08/09/2024, for the Certification of Terminal Illness Period 08/09/2024 to 10/07/2024. The clinical record documents routine nurse visits on 08/13/2024, 09/10/2024, 09/17/2024, and 09/29/2024. The clinical record lacks documented evidence of an updated comprehensive assessment that includes patients progress toward desired outcomes, and response to care every 15 days. On 10/03/2024 at 01:05PM, the Administrator, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 4. Patient #4 has a Start of Care date of 07/17/2024 with the following diagnoses “Malignant Neoplasm of Prostate, Secondary and Unspecified Malignant Neoplasm of Lymph Node, Atherosclerotic Heart Disease” documented in the Physicians Orders/ Plan of Care for the Certification Period 07/17/2024 to 10/14/2024. The clinical record documents routine nurse visits on 07/18/2024, 07/24/2024, 07/30/2024, 08/05/2024, 08/15/2024, 08/22/2024, 08/28/2024, 09/06/2024, and 09/11/2024. The clinical record lacks documented evidence of an updated comprehensive assessment that includes patients progress toward desired outcomes, and response to care every 15 days. On 10/03/2024 at 01:05PM, the Administrator, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 5. Patient #5 has a Start of Care date of 08/22/2024 with the following diagnoses “End Stage Renal Disease, Unspecified Dementia with Anxiety” documented in the Physicians Orders/ Plan of Care as of 08/22/2024, for the Certification of Terminal Illness Period 08/22/2024 to 10/20/2024. The clinical record documents routine nurse visits on 08/29/2024, 09/05/2024, 09/12/2024, 09/19/2024, and 09/26/2024. The clinical record lacks documented evidence of an updated comprehensive assessment that includes patients progress toward desired outcomes, and response to care every 15 days. On 10/03/2024 at 01:05PM, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 6. Patient #6 has a Start of Care date of 06/28/2024 with the following diagnoses “Atherosclerotic Heart Disease, Dementia” documented in the Physicians Orders/ Plan of Care as of 06/28/2024, for the Certification of Terminal Illness Period 06/28/2024 to 09/25/2024. The clinical record documents routine nurse visits on 07/02/2024, 07/11/2024, 07/18/2024, 07/23/2024, 08/01/2024, 08/08/2024, and 08/15/2024. The clinical record lacks documented evidence of an updated comprehensive assessment that includes patients progress toward desired outcomes, and response to care every 15 days. On 10/04/2024 at 01:07PM, the Administrator, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 7. Patient #7 has a Start of Care date of 06/12/2024 with the following diagnoses “Dementia, Pressure Ulcer of Right Hip Stage 4, Pressure Ulcer of Left Hip Stage 4” (the most severe type of PU and involves full-thickness tissue loss with exposed bone, tendon, or muscle) documented in the Physicians Orders/ Plan of Care for the Certification Period 06/12/2024 to 09/04/2024. The Initial Visit (comprehensive assessment) dated 06/12/2024 documents: Left Hip, pressure ulcer, Stage 4 (the most severe type of PU and involves full-thickness tissue loss with exposed bone, tendon, or muscle), not measured, beefy red, Epithelial, Slough 1%, Granulation 99%. Right Hip, pressure ulcer, Stage 4, (the most severe type of PU and involves full-thickness tissue loss with exposed bone, tendon, or muscle) not measured, pink, beefy red, granulation 100%. Lower Right Hip, pressure ulcer, Unstageable, (a wound that is either a stage 3 or 4 pressure ulcer, but is covered by slough or eschar, making it impossible to determine stage) not measured, Eschar 100%. The clinical record documents routine nurse visits on 07/02/2024, 07/11/2024, 07/18/2024, 07/23/2024, 08/01/2024, 08/08/2024, and 08/15/2024. The clinical record lacks documented evidence of the following wound assessments:Left Hip on 06/28/2024, 07/05/2024, 07/12/2024, 07/26/2024, 08/02/2024, 08/29/2024. Right Hip on 06/28/2024, 07/05/2024, 07/12/2024, 07/26/2024, 08/02/2024, 08/29/2024. Lower Right Hip on 08/29/2024. The clinical record lacks documented evidence of an updated comprehensive assessment that includes wound assessment, patients progress toward desired outcomes, and response to care every 15 days. On 10/04/2024 at 01:07PM, the Administrator, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings.”

“Based on clinical record review and staff interview the hospice failed to ensure that the patient’s plan of care is individualized, patient - specific, and integrate changes based on assessment findings. This was evident for thirteen (13) of twenty-nine (29) clinical records reviewed. (Patient #1, #2, #3, #5, #11, #12, #16, #17, #18, #21, #22, #23, #24). Failure to ensure that the patients plan of care is individualized, patient - specific, clear, concise and integrate changes based on assessment findings has the potential for negative patient outcome. The findings are: 10. Patient # 21has a Start of Care date of 8/19/2024 with diagnoses of Malignant Neoplasm of Pancreas, unspecified and Malignant Neoplasm of unspecified part of unspecified bronchus or lung documented on the Physicians Orders/Plan of Care with a Certification Period from 8/19/2024 to11/16/2024. The Physicians Orders/Plan of Care with a Certification Period from 8/19/2024 to 11/16/2024 lacks documented evidence of DME/Supplies (Durable Medical Equipment/Supplies), safety measures, functional limitations, and activities permitted. On 10/03/2024 at 01:05 PM, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 11.Patient #22 has a Start of Care date of 8/11/24 with diagnoses of Malignant Neoplasm of unspecified part of unspecified bronchus or lung, and Unspecified Sequelae of unspecified Cerebrovascular Disease documented on the Physicians Orders/Plan of Care with a Certification Period from 8/11/2024 to 11/8/2024. The supplemental order as of 8/15/24 documents, “;8-11-24 Hydromorphone HCL (Hydrochloride) by mouth tablet 2 mg 1 tab(s) every 3 hours prn PO for pain (2 milligrams, 1 tablet every 3 hours as needed by mouth for pain).” The Initial Nurse Practitioner visit “;Charts/Clinical Notes” with and “Effective Date: 9/11/24” with a signed date of 9/11/24 documents, “;Clinically patient has pain, she is currently on Methadone 2.5 mg (milligrams) BID (twice a day) and hydromorphone 2 mg q 4h prn (2 milligrams every 4 hours as needed).” There is no documented evidence of a Physicians Order/Plan of Care that includes hydromorphone 2 mg q 4h prn (2 milligrams every 4 hours as needed). On 10/03/2024 at 01:05 PM, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 12.Patient #23 has a Start of Care date of 5/30/24 with diagnoses of Cerebrovascular Disease, unspecified and Vascular Dementia documented on the Physicians Orders/Plan of Care with a Certification Period from 5/30/24 to 8/27/24. The Physicians Orders/Plan of Care “;as of 8/28/24” lacks documentation of DME/Supplies (Durable Medical Equipment/Supplies), safety measures, functional limitations, and activities permitted. The Physicians Orders/Plan of Care “;as of 8/28/24” documents, “;Start of Certification Period 5/30/24, End of Certification Period 8/27/24.” The clinical record documents nursing visits were conducted on 8/28/24, 9/5/24, 9/13/24, and 9/26/24, after the “;End Certification Period 8/27/24.” The plan of care lacks documented evidence of an accurate end of certification period date. On 10/03/2024 at 01:05 PM, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 13.Patient #24 has a Start of Care date with a diagnosis of Unspecified Sequelae of unspecified Cerebrovascular Disease documented on the Physicians Orders/Plan of Care with a Certification Period from 6/10/24 to 9/7/24. The clinical record documents RN (Registered Nursing) visits conducted on 6/20/24, 6/25/24, 7/1/24, 7/11/24, 7/15/24, 7/17/24, 7/19/24, 7/23/24, 7/26/24, 7/27/24, 7/29/24, 8/2/24, 8/5/24, 8/10/24, 8/13/24, 8/15/24, 8/20/24, 8/23/24, 8/27/24, 9/3/24 and 9/5/24. The Physicians Orders/Plan of Care lacks documented evidence of orders for the frequency of RN visits. The clinical record documents the RN conducting supervision of the home health aide on 6/20/24, 6/25/24, 7/1/24, 7/11/24, 7/15/24, 7/23/24, 7/29/24, 8/2/24, 8/5/24, 8/13/24, 8/20/24, 8/27/24, and 9/3/24. The Physicians Orders/Plan of Care lacks documented evidence of orders for the frequency of home health aide services. The clinical record documents Social Work visits on 6/11/24, 6/18/24, 6/26/24, 7/2/24, 7/11/24, 7/17/24, 7/23/24, 8/2/24, 8/5/24, 8/12/24, 8/20/24, and 9/5/24. The Physicians Orders/Plan of Care lacks documented evidence of orders for the frequency of Social Work visits. The clinical record documents Musical Therapy visits on 7/29/24, 8/5/24, 8/12/24, and 8/26/24. The Physicians Orders/Plan of Care lacks documented evidence of orders for the frequency of Music Therapy visits. The RN (Registered Nurse) “;Charts/Clinical Notes” with and “;Effective Date: 8/10/24 documents, “;The left hip has a stage II (an open sore or blister that forms when the skin’s epidermis or dermis is damaged) wound. Cleansed the wound with wound spray and Dakins solution. Patted area dry. Applied hydrogel and covered the wound with a bordered dressing. There is no documented evidence of a physician’s order for cleansing the wound with Dakins solution and applying hydrogel. The Physicians Orders/Plan of Care “;as of 9/8/24” documents, “;Start of Certification Period 6/10/24, End of Certification Period 9/7/24.” The clinical record documents nursing visits being conducted on 9/9/24, 9/13/24, 9/24/24, 9/25/24, and 9/27/24 after the “;End Certification Period 9/7/24.” The Physicians Orders/Plan of Care lacks documented evidence of an accurate end of certification period and documentation of DME/Supplies (Durable Medical Equipment/Supplies), safety measures, functional limitations, and activities permitted. On 10/04/2024 at 01:07 PM, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 7.Patient #16 has a Start of Care date of 9/05/2024 with diagnoses of Alzheimers disease, unspecified documented on the Physician’s Order/ Plan of Care as of 9/05/2024. The Physicians Orders/Plan of Care for the Certification Period from 9/05/2024 to 11/03/2024 lacks documented evidence of Prognosis, DME (Durable Medical Equipment)/Supplies, Safety Measures, Nutrition, Functional Limitation, Activities Permitted, Mental Status. On 10/03/2024 at 01:05 PM, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 8.Patient #17 has a Start of Care date of 8/30/2024 with diagnoses of parkinsonism, unspecified documented on the Physician’s Order/ Plan of Care as of 8/30/2024. The Physicians Orders/Plan of Care for the Certification Period from 8/30/2024 to 1/27/2024 lacks documented evidence of Prognosis and Safety Measures. On 10/03/2024 at 01:05 PM, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 9.Patient #18 has a Start of Care date of 08/30/2024 with diagnoses of Unspecified dementia, unspecified severity, without behavior disturbance, psychotic disturbance, mood disturbance, and anxiety documented on the Physician’s Order/ Plan of Care as of 08/30/2024. The Physicians Orders/Plan of Care for the Certification Period from 8/30/2024 to 11/27/2024 lacks documented evidence of Prognosis, DME (Durable Medical Equipment)/Supplies, Safety Measures, Nutrition, Functional Limitation, Activities Permitted, Mental Status. On 10/03/2024 at 01:05PM, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 5.Patient #11 has a Start of Care date of 09/04/2024 with the following diagnoses “Pulmonary Fibrosis, Systemic Lupus Erythematosus, Malignant Neoplasm of Colon” documented on the Physicians Orders/Plan of Care for the Certification Period 09/04/2024 to 12/02/2024. The Physicians Orders/Plan of Care for the Certification Period 09/04/2024 to 12/02/2024 lacks documented evidence of DME (Durable Medical Equipment)/Supplies, Safety Measures, Nutrition and Allergies, Functional Limitation, Activities Permitted, Mental Status. On 10/03/2024 at 03:00 PM, the Administrator/CEO (Chief Executive Officer), the Assistant Director of QAPI (Quality Assurance and Performance Improvement)/Educator, the Registered Nurse Staff Educator, the Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 6.Patient #12 has a Start of Care date of 08/20/2024 with the following diagnoses “Chronic Obstructive Pulmonary Disease, Unspecified Dementia, Essential (primary) Hypertension” documented on the Physicians Orders/Plan of Care for the Certification Period 08/20/2024 to 11/17/2024. The IDT (Interdisciplinary Team) Summary/Attending Physician Update dated 09/04/2024 documents: “Comments: ... on continuous Oxygen, transfer via Hoyer Lyft.” The Physicians Orders/Plan of Care for the Certification Period 08/20/2024 to 11/17/2024 lacks documented evidence of the DME (Durable Medical Equipment)/Supplies, Safety Measures, Nutrition, Functional Limitation, Activities Permitted, Mental Status. On 10/03/2024 at 03:00 PM, the Administrator/CEO (Chief Executive Officer), the Assistant Director of QAPI (Quality Assurance and Performance Improvement)/Educator, the Registered Nurse Staff Educator, the Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 1. Patient #1 has a Start of Care date of 01/16/2024 with the following diagnoses “Senile Degeneration of Brain, Dementia” documented in the Physicians Orders/ Plan of Care as of 09/12/2024, for the Certification of Terminal Illness Period 09/12/2024 to 11/10/2024. The Physicians Orders/ Plan of Care as of 09/12/2024 documents: Start of Certification Period 01/16/2024; End of Certification Period 04/14/2024 and Mucinex 15 ml (milliliter) PRN PO (as needed by mouth). The clinical record documents nurse visits on the following dates: 09/17/21024, 09/23/2024, 09/24/2024, 09/26/2024, and 09/30/2024. The plan of care lacks documented evidence of an accurate end of the certification period date, hospice continues to provide services after 4/14/2024, including the patient receiving the medication Mucinex. On 10/03/2024 at 01:05 PM, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 2. Patient #2 has a Start of Care date of 07/26/2024 with the following diagnoses “Senile Degeneration of Brain, Dementia” documented in the Physicians Orders/ Plan of Care for the Certification Period 07/26/2024 to 10/23/2024. The Initial Visit dated 07/26/2024 documents: Sacrum, pressure ulcer, Stage 3, (full thickness tissue loss that extends into the deeper tissue and fat, but doesn’t expose bone, tendon, or muscle) not measured, beefy red. The Physicians Orders/ Plan of Care for the Certification Period 07/26/2024 to 10/23/2024 lacks documented evidence of the monitoring and treatment for the sacral pressure ulcer. On 10/03/2024 at 01:05 PM, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 3. Patient #3 has a Start of Care date of 10/14/2023 with the following diagnoses “Senile Degeneration of Brain, Dementia” documented in the Physicians Orders/ Plan of Care as of 08/09/2024, for the Certification of Terminal Illness Period 08/09/2024 to 10/07/2024. The Physicians Orders/ Plan of Care as of 08/09/2024 documents Start of Certification Period 10/14/2023; End of Certification Period 01/11/2024. The clinical record documents services being provided by the Nurse on 08/13/21024, 08/22/2024, 08/27/2024, 09/10/2024, 09/17/2024, 09/29/2024, and 10/01/2024; the social worker on 08/27/2024 and 09/12/2024; the music therapy on 09/06/2024; and Pastoral care on 08/13/2024, 08/26/2024, 09/09/2024, and 09/232024. The plan of care lacks documented evidence of an accurate end of certification period date and no orders for the services being provided after 1/11/2024. On 10/03/2024 at 01:05 PM, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 4. Patient #5 has a Start of Care date of 08/22/2024 with the following diagnoses “End Stage Renal Disease, Unspecified Dementia with Anxiety” documented in the Physicians Orders/ Plan of Care as of 08/22/2024, for the Certification of Terminal Illness Period 08/22/2024 to 10/20/2024. The clinical record documents services being provided by the Nurse on 08/22/2024, 08/24/2024, 08/29/2024, 09/12/2024, 09/20/2024, and 09/26/2024; and the social worker on 08/23/2024, 09/05/2024, and 09/19/2024. The Physicians Orders/Plan of Care as of 08/22/2024 lacks documented evidence of DME (durable medical equipment)/ Supplies, Safety Measures, Nutrition, treatment, and services provided. On 10/03/2024 at 01:05 PM, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings.”

“Based on clinical record review and staff interview the hospice failed to ensure the plan of care documents all treatments and drugs necessary to meet the need of the patient. This was evident for two (2) of twenty-nine (29) clinical records reviewed. (Patient #21 and #23). Failure to ensure the plan of care documents all treatments and drugs necessary to meet the needs of the patient has the potential for negative patient outcome. The findings are: 1.Patient #21 has a Start of Care date of 8/19/2024 with diagnoses of Malignant Neoplasm of Pancreas, unspecified and Malignant Neoplasm of unspecified part of unspecified bronchus or lung documented on the Physicians Orders/Plan of Care with a Certification Period from 8/19/2024 to 11/16/2024. The RN (Registered Nurse) “;Charts/Clinical Notes” with an “;Effective Date: 8/19/24” documents, “;Has weeping edema to bilateral legs. Legs wrapped with conforming gauzes.” The IDT (Interdisciplinary Team) Summary/Attending Physician Update dated 8/21/24, documents, “;Has weeping edema to BLE (Bilateral Lower Extremity) wrapped with gauze cling.” The RN visit note dated 8/26/24 documents “;Instructed On: Other: Wrapping weeping legs with conformed gauzes. Instructions: Pt, PCG (Patient, Patient Caregiver), Other – Verbal instruction given to.” The IDT (Interdisciplinary Team) Summary/Attending Physician Update dated 9/4/24 documents, “;Weeping edema to BLE (Bilateral Lower Extremity), wrapped with cling.” The RN visit note dated 9/16/24 documents, “;Instructed on: Universal precautions, Other: legs wrapped due to weeping edema. PCG (Patient/Caregiver), Other - Verbal instruction given to.” There is no documented evidence of physician orders that includes the treatment for the patients bilateral lower extremity edema and to wrap in gauze. On 10/03/2024 at 01:05 PM, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 2.Patient #23 has a Start of Care date of 5/30/24 with diagnoses of Cerebrovascular Disease, unspecified and Vascular Dementia documented on the Physicians Orders/Plan of Care with a Certification Period from 5/30/24 to 8/27/24. The RN (Registered Nurse) visit note dated 6/11/24 documents a wound on the sacrum, “;Stage 2 (an open sore or blister that forms when the skin’s epidermis or dermis is damaged) . . . Wound Measurement: Length in centimeters: 1.5, width in centimeters: 1.5, Incision/Wound Tissue Observed: Pink . . . Dressing Changed this Visit: Yes, per orders, see Care Plan.” The RN “Charts/Clinical Notes” with an “Effective Date: 6/11/24” documents, “Patient has a small open sore around tip of penis with signs and symptoms of an infection. Patient has fungal rash around the genital area as well. Conferred with (names of physicians) to place patient on antibiotics. Fluconazole 150 mg tab (milligram tablet) and Nystatin powder ordered with (name of pharmaceutical company).” The RN visit note dated 6/20/24 documents, “Sacrum . . .. Dressing Changed this Visit: Yes, per orders, see Care Plan.” The RN “;Charts/Clinical Notes” with an “Effective Date: 6/20/24” documents, “;Open sore around tip of penis is healing with no sign and symptoms of an infection. Patients fungal rash around the genital area is healing as well. Patient finished course of antibiotics of Fluconazole150 mg tab (tablet) and Nystatin powder to rash area. Sacral pressure ulcer (wound in the skin and tissue that occurs when pressure is applied to the same area of skin for a long time) cleaned and bandaged following wound care POC (Plan of Care). The RN “;Charts/Clinical Notes” with an “Effective Date: 6/26/24” documents, “;Patient has shearing on both buttocks . . .. Cleaned patient with wound care spray and slathered zinc ointment on area. PU (Pressure Ulcer) (wound in the skin and tissue that occurs when pressure is applied to the same area of skin for a long time) has healed but is still red and fragile.” The clinical record documents the patients wounds were healed on 7/8/24. The RN “Charts/Clinical Notes” with an “Effective Date: 7/8/24” documents, “Checked skin for s/s (signs and symptoms) of breakdown. Skin intact.” There is no documented evidence of wound care orders for the patients pressure ulcer (wound in the skin and tissue that occurs when pressure is applied to the same area of skin for a long time) and treatment for the shearing on patients buttocks. There is no documented evidence of physicians orders for Fluconazole 150 mg tab and Nystatin powder. On 10/03/2024 at 01:05 PM, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings.”

“Based on clinical record review and staff interview, the hospice failed to ensure the Interdisciplinary Group (IDG) reviewed and revised the individualized Plan of Care (POC) as the patient’s care needs change, but no less frequently than every fifteen (15) days. This was evident for nine (9) of twenty-nine (29) clinical records reviewed (Patient #1, #2, #4, #5, #6, #7, #18, #22, and #23). Failure of the Interdisciplinary Group to develop, review, and revise the Plan of Care has the potential for negative patient outcomes. The findings are: 8.Patient #22 has a Start of Care date of 8/11/2024 with diagnoses of Malignant Neoplasm of unspecified part of unspecified Bronchus or Lung, and Unspecified Sequelae of unspecified Cerebrovascular Disease documented on the Physicians Orders/Plan of Care with a Certification Period from 8/11/2024 to 11/8/2024. The Initial Nurse Practitioner visit “;Charts/Clinical Notes” with an “Effective Date: 9/11/24” and a signed date of 9/11/24 documents, “;Plan: Nutrition-continue diet as tolerated, aspiration precaution, maintain HOB (Head of Bed) elevated during and after eating, use thick it . . .. Pain – morphine 5 mg q 3h prn (morphine 5 milligrams, every 3 hours as needed), continue Tylenol 650 mg q6h prn (650 milligrams every 6 hours as needed) . . .. Agitation – Haldol 1mg q1hr prn (Haldol 1 milligram every 1 hour as needed) Skin breakdown preventions – turn and reposition q2h (every 2 hours), elevate bony prominences on pillow, apply emollients frequently.” There is no documented evidence of a revised Physicians Orders/Plan of Care that includes aspiration precautions, maintain HOB elevated during and after eating, using thick it, administering Tylenol for pain, administering Haldol 1mg q 1 hr. prn, and skin breakdown prevention. The “;Active Orders” with a start date of 8/11/24 documents, “;Oxygen 2 L per min PRN via nasal cannula for SOB (Oxygen 2 liters per minute as needed by nasal cannula for shortness of breath).” The initial RN (Registered Nurse) comprehensive assessment visit dated 8/11/2024 documents, “;Home Fire Safety, Yes – oxygen safety measures in place, Yes – No smoking materials in the home, Yes- No potential for open flames.” The initial SW (Social Worker) visit note dated 8/11/24 documents, “;Tobacco: Current use: Patient smokes. The niece allows her to smoke limited number of cigarettes in the day. She holds the cigarettes.” The Interdisciplinary Summary/Attending Physician Update documents meetings dated 8/15/2024, 8/29/2024, 9/12/2024, and 9/26/2024. There is no documented evidence of the Interdisciplinary Team reviewing and revising the patients plan of care safety measures due to the patient being an active smoker and was ordered oxygen. On 10/3/2024 at 10:45 AM, the Staff Educator was interviewed and stated, “;I called the oxygen company and family . . . no oxygen in the home and has never been. It was an entry error.” On 10/03/2024 at 01:05 PM and 10/04/2024 at 01:07 PM, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 9.Patient #23 has a Start of Care date of 5/30/2024 with diagnoses of Cerebrovascular disease, unspecified and Vascular dementia documented on the Physicians Orders/Plan of Care with a Certification Period from 5/30/2024 to 8/27/2024. The clinical record documents the patient had a skin tear on the right shin on 5/30/2024, 6/2/2024, and 6/6/2024. The clinical record documents the patient had a right shin and left forearm skin tears on 6/11/2024 and 6/20/2024. The clinical record documents the skin tears were healed on 7/1/2024. The RN (Registered Nurse) visit note dated 6/11/2024 documents a wound on the sacrum, “;Stage 2 (an open sore or blister that forms when the skin’s epidermis or dermis is damaged) . . . Wound Measurement: Length in centimeters: 1.5, width in centimeters: 1.5, Incision/Wound Tissue Observed: Pink . . . Dressing Changed this Visit: Yes, per orders, see Care Plan.” The clinical record documents the patients pressure ulcer was healed on 7/1/2024. The RN “Charts/Clinical Notes” with an “Effective Date: 6/11/24” documents, “Patient has a small open sore around tip of penis with signs and symptoms of an infection. Patient has fungal rash around the genital area as well. Conferred with (names of physicians) to place patient on antibiotics. Fluconazole 150 mg tab (milligram tablet) and Nystatin powder ordered with (name of pharmaceutical company).” The RN “;Charts/Clinical Notes” dated 6/20/2024 documents, “;Open sore around tip of penis healing with no sign and symptoms of an infection.” The “;Interdisciplinary Summary/Attending Physician Update” documents meetings dated 6/5/2024, 6/12/2024, and 6/26/2024. The Interdisciplinary Team (IDT) lacks documentation of reviewing the patients skin tears, sacral pressure ulcer, (wound in the skin and tissue that occurs when pressure is applied to the same area of skin for a long time) and open sore around tip of penis during the IDT meetings. The Physician “;Charts/Clinical Notes” with an “;Effective Date: 09/19/2024, documents, “;Clinically, his vascular ulcer (wounds on the skin that develop because of problems with blood circulation) has been worsening despite adequate treatment measures being undertaken due to his overall poor and worsening cardiovascular and overall condition.” The “;Interdisciplinary Summary/Attending Physician Update” documents a meeting dated 9/25/2024. There is no documented evidence of the Interdisciplinary Team (IDT) reviewing the patient’s vascular ulcer status during the IDT meetings. On 10/03/2024 at 01:05 PM and 10/04/2024 at 01:07 PM, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 7. Patient #18 has a Start of Care date of 08/30/2024 with diagnoses of Unspecified dementia, unspecified severity, without behavior disturbance, psychotic disturbance, mood disturbance, and anxiety documented on the Physician’s Order/ Plan of Care as of 08/30/2024. The Supplemental Orders dated 10/02/2024 documents: “;Per order, a change to treatments and or medications has occurred requiring your signature. Medications: 09/18/2024 Lactulose By Mouth 10 GM (Grams)/15 ML (Milliliters) 15mldaily PO (by mouth) for constipation.10/02/2024 Preparation H Hydrocortisone External Cream 1% 1 Application every 6 hours prn (as needed) per rectum for hemorrhoids. 09/11/2024 Senna By Mouth Tablet 8.6 MG (Milligrams) 2 tablets daily PO (by mouth) for constipation. The Routine Visit dated 09/06/2024 documents: “;Physical/Skin/Incision/Wound: Upper Back: Site Location: Upper Back; Type: Skin Tear. The Charts/Clinical Notes documents: 09/13/2024 “;Family stated patient has redness to perineal area but DO (Medical Doctor) is aware, but patient has some pain to area. Area observed to be red at this time. Writer reinforced the use of the medication to area. DO (Medical Doctor) made aware of patients pain, t/o (telephone order) Tylenol 650 mg q (every) 8 hours prn (as needed) for pain.” 09/17/2024” Family stated heel is wrapped, blister to area open a few days ago. Family stated patient has some pain during dressing change. Dressing observed to left heel, area is beefy pink. DO (Medical Doctor) made aware of heel and patients pain t/o (telephone order) Tylenol 1000 mg one time dose before dressing change to heel. Family updated and verbalized understanding. Area cleansed with NS (Normal Saline) spray, patted dry and triple antibiotic ointment applied and covered with confirming dressing.” There is no documented evidence of the supplemental order for new wound (Upper Back Skin Tear) treatment, for medication to be used to perineal area and Tylenol 650mg q (every) 8 hours prn (as needed) for pain. There is no documented evidence of the supplemental order for Tylenol 1000 mg one time dose before dressing change to Left Heel and a new treatment with NS (Normal Saline) spray and triple antibiotic ointment applied to Left Heel. There is no documented evidence of the IDG (Interdisciplinary Group) reviewing and revising the patients individualized plan of care at least every 15 days or as needed that includes medications and treatments. On 10/04/2024 at 01:07 PM, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 1. Patient #1 has a Start of Care date of 01/16/2024 with the following diagnoses “Senile Degeneration of Brain, Dementia” documented in the Physicians Orders/ Plan of Care as of 09/12/2024, for the Certification of Terminal Illness Period 09/12/2024 to 11/10/2024. The Visit Record documents:09/11/2024 excoriation to sacrum persists, Calmoseptine barrier cream continues upon each diaper change.09/17/2024, 09/23/2024, 09/24/2024, 09/30/2024 excoriation to sacrum persists, Calmoseptine barrier cream continues upon each diaper change.09/26/2024 Calmoseptine barrier cream continues upon each diaper change. The Interdisciplinary Team dated 09/17/2024 lacks documented evidence of the discussion of the excoriation on sacrum, patient with history of sacrum pressure ulcer. The team care plan lacks documented evidence to include the excoriation of sacrum to the alteration in skin integrity. The plan of care lacks documented evidence of the supplemental order for Calmoseptine. The Team Care Plan as of 09/30/2024 documents: “;Alteration in skin integrity – Intervention: commenced Cephalexin 500mg BID (twice a day) x 7D (days) ingrown toenail.” “;Start Date: 08/18/2024 Cephalexin by mouth Capsule 500 mg (milligram) 1 cap (capsule) twice per day po (by mouth).” The team care plan lacks documented evidence of the discontinuation of the antibiotic intervention.There is no documented evidence of the IDG (Interdisciplinary Group) reviewing and revising the patients individualized plan of care at least every 15 days or as needed that includes the treatment and discontinuation of medication. On 10/03/2024 at 01:05 PM, Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 2. Patient #2 has a Start of Care date of 07/26/2024 with the following diagnoses “Senile Degeneration of Brain, Dementia” documented in the Physicians Orders/ Plan of Care for the Certification Period 07/26/2024 to 10/23/2024. The Supplemental Orders as of 07/29/2024 documents: “;Wound Care 1 application two times per week topically Stage 3 PU (pressure ulcer) Sacrum (full thickness tissue loss that extends into the deeper tissue and fat, but doesn’t expose bone, tendon, or muscle) – Cleanse wound with wound cleanser and pat dry. Apply Medi-honey on wound and cover with 4x4 gauze and apply protective dressing.” The Charts/Clinical Notes documents: 08/06/2024 “;Redness noted on L (left) butt (buttock) cheek. Dressing changed and Zinc Oxide applied to reddened area.”08/20/2024 “;fleet enemas were ordered for constipation.”08/26/2024 “;Zinc Oxide will be added to wound care regimen.”09/05/2024 “;PU (pressure ulcer) (wound in the skin and tissue that occurs when pressure is applied to the same area of skin for a long time) on R (right) butt (buttock) cheek has healed.”09/10/2024 “;PU (pressure ulcer) (wound in the skin and tissue that occurs when pressure is applied to the same area of skin for a long time) on R (right) butt (buttock) cheek reopened to a stage 2. Dressing changed as per wound care order. There is no documented evidence of the supplemental order for Zinc Oxide, Fleet enema, discontinuation of Medi-Honey, and a new order for the reopened pressure ulcer. There is no documented evidence of the IDG (Interdisciplinary Group) reviewing and revising the patients individualized plan of care at least every 15 days or as needed that includes the treatment and constipation. On 10/03/2024 at 01:05PM, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 3. Patient #4 has a Start of Care date of 07/17/2024 with the following diagnoses “Malignant Neoplasm of Prostate, Secondary and Unspecified Malignant Neoplasm of Lymph Node, Atherosclerotic Heart Disease” documented in the Physicians Orders/ Plan of Care for the Certification Period 07/17/2024 to 10/14/2024. The Hospice Home Health Aide Plan of Care and Weekly Notes documents aide services being provided on 08/05/2024 to 08/09/2024, 08/13/2024 to 08/16/2024, 08/19/2024, 08/26/2024 to 08/30/2024, 09/03/2024 to 09/06/2024, and 09/10/2024 to 09/13/2024. The clinical record lacks documented evidence of the Plan of Care being reviewed and revised for the order of hospice aide/home health aide services.There is no documented evidence of the IDG (Interdisciplinary Group) reviewing and revising the patients individualized plan of care at least every 15 days or as needed that includes the aide services. On 10/03/2024 at 01:05PM, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 4. Patient #5 has a Start of Care date of 08/22/2024 with the following diagnoses “End Stage Renal Disease, Unspecified Dementia with Anxiety” documented in the Physicians Orders/ Plan of Care as of 08/22/2024, for the Certification of Terminal Illness Period 08/22/2024 to 10/20/2024. The Initial Visit dated 08/22/2024 documents: Redness to Sacrum; Instructed on: pressure relief measures, incontinent management. The Charts/Clinical Notes documents:08/24/2024 “;She has not had a bowel movement in the past 24 hours.”08/29/2024 “;Skin redness to sacrum and stage 2 PU (pressure ulcer) (an open sore or blister that forms when the skin’s epidermis or dermis is damaged) to left hip. Area was cleansed, patted dry and Zinc Oxide applied.”09/20/2024 “;Lactulose 10 mg/15ml.” The clinical record lacks documented evidence of the order for Zinc Oxide and Lactulose. The Plan of Care lacks documented evidence of the goals and intervention of bowel elimination. There is no documented evidence of the IDG (Interdisciplinary Group) reviewing and revising the patients individualized plan of care at least every 15 days or as needed that includes wound treatment and bowel elimination. On 10/03/2024 at 01:05 PM, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 5. Patient #6 has a Start of Care date of 06/28/2024 with the following diagnoses “Atherosclerotic Heart Disease, Dementia” documented in the Physicians Orders/ Plan of Care as of 06/28/2024, for the Certification of Terminal Illness Period 06/28/2024 to 09/25/2024. The Charts/Clinical Notes documents:06/29/2024 “;pt (patient) having more frequent seizures.”07/23/2024 “;New order placed for Amlodipine.”08/01/2024 “;Pt (patient) noted to have a small red area by the sacrum. Zinc Oxide applied.”08/05/2024 “;Pt (patient) has been suffering from constipation.”09/12/2024 “;pt (patient) had fell out of wheelchair.” “;Pt (patient) observed to have 2 hematomas on her head and was unable to move her right arm.” The clinical record lacks documented evidence of the order for Amlodipine and Zinc Oxide. The Plan of Care lacks documented evidence of the goals and intervention of skin integrity, fall/safety, pain, and bowel elimination. There is no documented evidence of the IDG (Interdisciplinary Group) reviewing and revising the patients individualized plan of care at least every 15 days or as needed including medication, treatment, safety, and bowel elimination. On 10/04/2024 at 01:07 PM, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 6. Patient #7 has a Start of Care date of 06/12/2024 with the following diagnoses “Dementia, Pressure Ulcer of Right Hip Stage 4, Pressure Ulcer of Left Hip Stage 4” (the most severe type of pressure ulcer and involves full-thickness tissue loss with exposed bone, tendon, or muscle) documented in the Physicians Orders/ Plan of Care for the Certification Period 06/12/2024 to 09/04/2024. The Charts/Clinical Notes dated 06/12/2024 documents: “;has stage IV pressure ulcers (the most severe type of pressure ulcer and involves full-thickness tissue loss with exposed bone, tendon, or muscle) to right and left hips with small unstageable pressure (a wound that is either a stage 3 or 4 pressure ulcer, but is covered by slough or eschar, making it impossible to determine stage),also on right hip. Daughter provides daily wound care applying Aquacel dressing to wounds.” The plan of care lacks documented evidence of the order of Aquacel to pressure ulcers. The Supplemental Orders dated 06/14/2024 documents: “;Dakins External Solution 0.5% 1 application three times per week Wound Care.” The Supplemental Order for the wound care Dakins lacks documented evidence of the location/site of wound to be treated. There is no documented evidence of the IDG (Interdisciplinary Group) reviewing and revising the patients individualized plan of care at least every 15 days or as needed . On 10/04/2024 at 01:07 PM, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings.”

“Based on clinical record review and staff interview, the hospice agency failed to ensure the Interdisciplinary Group (Interdisciplinary Team) develop, maintain, coordination, and supervise all care and services being provided. This was evident for six (6) of twenty-nine (29) clinical records reviewed (Patients #2, #3, #6, #7, #9, and #22). Failure to ensure the Interdisciplinary Group (Interdisciplinary Team) develop, maintain, coordinate, communicate, and supervise all care and services being provided, has the potential for negative patient outcomes. The findings are: 6.Patient #22 has a Start of Care date of 8/11/2024 with diagnoses of Malignant Neoplasm of unspecified part of unspecified Bronchus or Lung, and Unspecified Sequelae of unspecified Cerebrovascular Disease documented on the Physicians Orders/Plan of Care with a Certification Period from 8/11/2024 to 11/8/2024. The “;Active Orders” with a Start Date of 8/1120/24 documents, “;Oxygen 2 L per min PRN via nasal cannula for SOB (Oxygen 2 liters per minute as needed by nasal cannula for shortness of breath).” The Initial RN (Registered Nurse) comprehensive assessment visit dated 8/11/2024 documents, “;Home Fire Safety, Yes – oxygen safety measures in place, Yes – No smoking materials in the home, Yes- No potential for open flames.” The Initial SW (Social Worker) visit note dated 8/11/2024 documents, “;Tobacco: Current use: Patient smokes. The niece allows her to smoke limited number of cigarettes in the day. She holds the cigarettes.” The Interdisciplinary Summary/Attending Physician Update meetings dated 8/15/24, 8/29/24, 9/12/24, and 9/26/24 lack documentation that the patient is an active smoker and was ordered oxygen. On 10/3/24 at 10:45 AM , the Staff Educator was interviewed and stated, “;I called the oxygen company and family . . . no oxygen in the home and has never been. It was an entry error.” On 10/03/2024 at 01:05 PM and on 10/04/2024 at 01:07 PM, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 5.Patient #9 has a Start of Care date of 03/20/2024 with the following diagnoses “Unspecified Sequelae of Unspecified Cerebrovascular Disease, Dementia, Type 2 Diabetes Mellitus without Complications, Essential (Primary) Hypertension” documented on the Physicians Orders/Plan of Care for the Certification Period 06/18/2024 to 09/15/2024 and 09/16/2024 to 11/14/2024. The Hospice RN (Registered Nurse) Routine Visit dated 09/24/2024 documents: “Site Location: Right Gluteal; Type: Skin tear; Healing: Healed” On 10/01/2024, a home visit (HV) was conducted. The Skilled Nurse was observed cleaning the wound with wound cleanser and applying Zinc Oxide on the gluteal region. The Assistant Director of QAPI (Quality Assurance and Performance Improvement)/Educator and the Registered Nurse were interviewed and stated that the skin tear was healed, and Zinc Oxide was applied as a barrier. The clinical record lacks documented evidence of the supplemental order for Zinc Oxide treatment. The clinical record lacks documented evidence of the Skilled Nurse communicating with the Physician regarding changes in wound status- healed on 09/24/2024 or continue treatment. On 10/03/2024 at 03:00 PM, the Administrator/CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement)/Educator, Registered Nurse Staff Educator, Registered Nurse Auditor were interviewed and did not provide an explanation for the findings 1. Patient #2 has a Start of Care date of 07/26/2024 with the following diagnoses “Senile Degeneration of Brain, Dementia” documented in the Physicians Orders/ Plan of Care for the Certification Period 07/26/2024 to 10/23/2024. The Initial Visit dated 07/26/2024 documents: Sacrum, pressure ulcer, Stage 3, (full thickness tissue loss that extends into the deeper tissue and fat, but doesn’t expose bone, tendon, or muscle) not measured, beefy red. The Routine Visit documents: 07/29/2024, 08/06/2024 Sacrum, pressure ulcer, Stage 3, (full thickness tissue loss that extends into the deeper tissue and fat, but doesn’t expose bone, tendon, or muscle) not measured, Pink, slough 50%.08/13/2024, 08/20/2024, 08/27/2024 Sacrum, pressure ulcer, Stage 3, (full thickness tissue loss that extends into the deeper tissue and fat, but doesn’t expose bone, tendon, or muscle) not measured, Pink.09/05/2024 Sacrum, Stage 3, (full thickness tissue loss that extends into the deeper tissue and fat, but doesn’t expose bone, tendon, or muscle) healed.09/10/2024, 09/19/2024, 09/26/2024 Sacrum, pressure ulcer, Stage 2, (an open sore or blister that forms when the skin’s epidermis or dermis is damaged) not measured, Pink. The IDT (Interdisciplinary Team) Summary documents:07/26/2024, 08/06/2024, 08/20/2024, 09/17/2024, 10/01/2024 stage 3 PU (pressure ulcer) on sacrum.09/03/2024 (no mention of pressure ulcer). The clinical record lacks documented evidence of the coordination and communication with the physician with the status of pressure ulcer- wound started as beefy red, then developed slough, then pink, healed, and reopen. The Charts/Clinical Notes dated 08/06/2024 documents: Redness noted on L (left) butt (buttock) cheek. The clinical record lacks documented evidence of coordination and communication with the physician about the new redness on the left buttock. On 10/03/2024 at 01:05 PM, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 2. Patient #3 has a Start of Care date of 10/14/2023 with the following diagnoses “Senile Degeneration of Brain, Dementia” documented in the Physicians Orders/ Plan of Care as of 08/09/2024, for the Certification of Terminal Illness Period 08/09/2024 to 10/07/2024. The Charts/Clinical Notes dated 08/13/2024 documents: “;Patients sz (seizure) increasing in frequency, now almost daily in the mornings.” The clinical record lacks documented evidence of the coordination and communication with the physician for the increasing in seizure frequency.The IDT (Interdisciplinary Team) dated 08/21/2024 and 09/04/2024 lacks documented evidence of the discussion regarding increasing seizure frequency. On 10/03/2024 at 01:05 PM, Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 3. Patient #6 has a Start of Care date of 06/28/2024 with the following diagnoses “Atherosclerotic Heart Disease, Dementia” documented in the Physicians Orders/ Plan of Care as of 06/28/2024, for the Certification of Terminal Illness Period 06/28/2024 to 09/25/2024. The Charts/Clinical Notes documents:06/29/2024 “;pt (patient) having more frequent seizures.”08/05/2024 “;Pt (patient) has been suffering from constipation, RN (registered nurse) notified.” The clinical record lacks documented evidence of the coordination and communication with the physician for seizure frequency and constipation.The IDT (Interdisciplinary Team) dated 07/11/2024 and 08/08/2024 lacks documented evidence of the discussion regarding seizure and constipation. On 10/04/2024 at 01:07 PM, the Administrator/ CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 4. Patient #7 has a Start of Care date of 06/12/2024 with the following diagnoses “Dementia, Pressure Ulcer of Right Hip Stage 4, Pressure Ulcer of Left Hip Stage 4”(the most severe type of pressure ulcer and involves full-thickness tissue loss with exposed bone, tendon, or muscle) documented in the Physicians Orders/ Plan of Care for the Certification Period 06/12/2024 to 09/04/2024. The Initial Visit dated 06/12/2024 documents: Left Hip, pressure ulcer, Stage 4, (the most severe type of pressure ulcer and involves full-thickness tissue loss with exposed bone, tendon, or muscle) not measured, beefy red, Epithelial, Slough 1%, Granulation 99%. Right Hip, pressure ulcer, Stage 4, (the most severe type of pressure ulcer and involves full-thickness tissue loss with exposed bone, tendon, or muscle) not measured, pink, beefy red, granulation 100%.Lower Right Hip, pressure ulcer, Unstageable, (a wound that is either a stage 3 or 4 pressure ulcer, but is covered by slough or eschar, making it impossible to determine stage), not measured, Eschar 100%. The Routine Visit documents:Left Hip:06/12/2024 Stage 4, (the most severe type of pressure ulcer and involves full-thickness tissue loss with exposed bone, tendon, or muscle) not measured, pink.07/19/2024 Unstageable, (a wound that is either a stage 3 or 4 pressure ulcer, but is covered by slough or eschar, making it impossible to determine stage), not evaluated.08/16/2024 Stage – not evaluated, 5x6.8, pink, Undermining location: 12 oclock.08/23/2024 Unstageable, (a wound that is either a stage 3 or 4 pressure ulcer, but is covered by slough or eschar, making it impossible to determine stage), 5x6.7x0.5 centimeters, tunnelling – absent. Right Hip:07/19/2024 Unstageable, (a wound that is either a stage 3 or 4 pressure ulcer, but is covered by slough or eschar, making it impossible to determine stage), not evaluated.08/16/2024 Stage – not evaluated, 4x7 centimeters, pink.08/23/2024 Stage – not evaluated, 3.8x7.8 centimeters, pink. Lower Right Hip:06/21/2024 Unstageable, (a wound that is either a stage 3 or 4 pressure ulcer, but is covered by slough or eschar, making it impossible to determine stage),(no measurement), Pink, surrounding edge of wound dark.06/28/2024 Unstageable, (a wound that is either a stage 3 or 4 pressure ulcer, but is covered by slough or eschar, making it impossible to determine stage), 3x4.4x0.5 centimeters, Slough 100%.08/16/2024 Unstageable, (a wound that is either a stage 3 or 4 pressure ulcer, but is covered by slough or eschar, making it impossible to determine stage),5x6 centimeters, Slough 25%, Granulation 75%, Undermining 1centimeters 5-6. The clinical record lacks documented evidence of the coordination and communication with the physician for the changes of the pressure ulcers.The IDT (Interdisciplinary Team) dated 06/18/2024,07/03/2024, 07/17/2024, 07/31/2024, 08/14/2024, and 08/28/2024 lacks documented evidence of the discussion regarding status of pressure ulcers. On 10/04/2024 at 01:07 PM, the Administrator/ CEO (Chief Executive Officer), The Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, the Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings.”

“Based on clinical record review and staff interview, the agency failed to ensure that services are provided in accordance with the Plan of Care. This was evident for five (5) of twenty-nine (29) clinical records reviewed (Patient: #9, #11, #21, #23, and #24). Failure to ensure that services are provided in accordance with the Plan of Care, has the potential for negative patient outcome. The findings are: 3.Patient #21 has a Start of Care date of 8/19/2024 with diagnoses of Malignant Neoplasm of pancreas, unspecified and Malignant Neoplasm of unspecified part of unspecified Bronchus or Lung documented on the Physicians Orders/Plan of Care with a Certification Period from 8/19/2024 to 11/16/2024. The “;Active Orders” with a Start Date of 8/19/2024 and End Date of 11/16/24 documents orders for Home Health Aide services “;5 x week x 13 weeks” (five times a week, times 13 weeks). There is no documented evidence of the hospice providing Home Health Aide services as ordered. On 10/03/2024 at 01:05 PM, the Administrator/CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement)/Educator, Registered Nurse Staff Educator, and the Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. On 10/4/2024 at 3:27 PM, the Project Manager was interviewed, and stated, “;The nurse said the patient declined Home Health Aide services. The nurse is going to write a late entry.” 4.Patient #23 has a Start of Care date of 5/30/2024 with diagnoses of Cerebrovascular Disease, unspecified and Vascular Dementia documented on the Physicians Orders/Plan of Care with a Certification Period from 5/30/2024 to 8/27/2024. The Physicians Orders/Plan of Care with a Certification Period from 5/30/2024 to 8/27/2024 documents orders for “;PRN (as needed) Skin Tears: Cleanse Skin Tears with NSS (Normal Saline Solution). Apply Bacitracin and DSD (Dry Sterile Dressing) daily. The clinical record documents the RN (Registered Nurse) performed wound care on the patients skin tears on the right shin on 5/30/2024, 6/2/2024, and 6/6/2024. The patient developed a skin tear on the left forearm on 6/11/2024. The clinical record documents the RN (Registered Nurse) performed wound care on the patients skin tears on the right shin and left forearm on 6/11/2024 and 6/20/2024. The clinical record documents the skin tears were healed on 7/1/2024. There is no documented evidence of the RN performing daily wound care from 5/30/2024 until the skin tears were healed on 7/1/2024. The “;Active Orders” with a start date of 8/5/2024 documents, “;Wound Care 1 treatment three times per week topically, Plan of Care: Spray venous ulcer (an open sore that develops on the leg when the veins aren’t working properly to pump blood back to the heart) with skin integrity cleaning spray, pat dry with gauze, apply mupirocin, apply non-stick gauze on top, place foam bandage and wrap with gauze bandage. Change 3 times a week or as needed.” The RN “;Charts/Clinical Notes” with an “;Effective Date: 8/12/24” documents, “;Venous ulcer (an open sore that develops on the leg when the veins aren’t working properly to pump blood back to the heart) right lower shin has healed with skin intact.” There is no documented evidence of the wound care being performed three (3) times a week as ordered from 8/5/2024 until the venous ulcer was healed on 8/12/2024. The Initial RN comprehensive assessment visit dated 6/1/2024 documents, “;Yes- oxygen safety measures in place.” The “;Active Orders” with a start date of 5/30/2024 documents orders for “;Respiratory: O2 2-4 L/min PRN for dyspnea or shortness of breath (Oxygen 2-4 liters per minute, as needed, for dyspnea or shortness of breath).” The “Physician’s Orders/Plan of Care” as of 8/28/2024 documents orders for, “Respiratory: O2 2-4 L/min PRN (as needed) for dyspnea or shortness of breath.” The RN (Registered Nurse) “;Clinical/Chart Notes” with an “;Effective Date of 9/1/2024” documents, “;5:58 PM Call from (name of RN) at (name of Assisted Living Facility) reporting patient had shortness of breath, oxygen saturation dropped to 80s but came back up to 91% with coughing and deep breathing exercises. Caller confirmed Morphine has not been given and pt (patient) doesnt have O2 (oxygen) in facility. Advised to administer Morphine if patient has SOB (shortness of breath) and O2 will be requested for delivery. 6:04 PM – (name of RN) called back request runner to visit to place oxygen on patient when it is delivered. Advised Ill request for oxygen delivery tomorrow instead since patient has been stabilized and Morphine is available to treat the shortness of breath if symptom returns. Call placed to (name of oxygen supply company) and confirmed patient had oxygen delivered on 5/31/24. (Name of RN) informed of same and she requested prescription to be faxed to facility in AM . . .” There is no documented evidence that the hospice assessed the patient’s need to have oxygen available on an ongoing basis, as needed, after the oxygen was delivered on 5/31/24. On 10/03/2024 at 01:05 PM, the Administrator/CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement)/Educator, Registered Nurse Staff Educator, and the Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 5.Patient #24 has a Start of Care date with a diagnosis of Unspecified sequelae of unspecified Cerebrovascular Disease documented on the Physicians Orders/Plan of Care with a Certification Period from 6/10/2024 to 9/7/2024. The Supplemental Orders (medical orders) as of 6/26/2024 documents, “;06/26/2024 Medihoney Ca (calcium) Alginate, 2 inches x (by) External Pad, 1 application three times weekly EX (name of cleanser) cleanse left hip wound with would cleanser, apply Medihoney and cover with dcd (dry covered dressing).” There is no documented evidence of the RN (Registered Nurse) performing wound care three times a week as ordered during the weeks of: 6/23/2024 to 7/13/2024 and 7/28/2024 to 9/21/2024. The RN (Registered Nurse) “;Charts/Clinical Notes” with and “;Effective Date: 8/10/24 documents, “;The left hip has a stage II wound (an open sore or blister that forms when the skin’s epidermis or dermis is damaged) . . .. Cleansed the wound with wound spray and Dakins solution. Patted area dry. Applied Hydrogel and covered the wound with a bordered dressing. The RN performed wound care that was not according to the Supplemental Orders (medical orders) dated 6/26/2024. There is no documented evidence of the RN performing wound care on the left hip on 9/13/2024 and 9/27/2024, according to the Supplemental Orders (medical orders) as of 6/26/2024. The clinical record documents a “;Hospice Home Health Aide Plan of Care and Weekly Notes,” dated 6/10/2024. The “;Hospice Home Health Aide Plan of Care and Weekly Notes,” dated 6/10/2024 assigns the Home Health aide to perform bed bath, skin care, mouth care, dress, diaper change, monitor BM (bowel movement), linen change, out of bed, and to assist with wheelchair on Monday, Tuesday, Wednesday, Thursday, and Friday. The “;Hospice Home Health Aide Plan of Care and Weekly Notes,” dated 6/10/2024 assigns the Home Health aide to perform shampoo on Monday and Friday. There is no documented evidence of the Home Health Aide performing these duties for the month of June 2024. On 10/04/2024 at 01:07 PM, the Administrator/CEO (Chief Executive Officer), Assistant Director of QAPI (Quality Assurance and Performance Improvement)/Educator, Registered Nurse Staff Educator, and the Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 1.Patient #9 has a Start of Care date of 03/20/2024 with the following diagnoses “Unspecified Sequelae of Unspecified Cerebrovascular Disease, Dementia, Type 2 Diabetes Mellitus without Complications, Essential (Primary) Hypertension” documented on the Physicians Orders/Plan of Care for the Certification Period 06/18/2024 to 09/15/2024 and 09/16/2024 to 11/14/2024. The Physicians Orders/Plan of Care dated 06/18/2024 documents: VO (volunteer) 06/18/2024 2-4 x month x 3 months (two to four times a month for three months) and the Physicians Orders/Plan of Care dated 06/18/2024 documents: VO (volunteer) 09/16/2024 2-4 x month x 3 months (two to four times a month for three months). The clinical records lack documented evidence of any volunteer visits. There is no documented evidence of an interim order(s) to discontinue VO (volunteer) services and there is no documented evidence that the services are being provided in accordance with the plan of care. On 10/03/2024 at 03:00 PM, the Administrator/CEO (Chief Executive Officer), the Assistant Director of QAPI (Quality Assurance and Performance Improvement)/Educator, Registered Nurse Staff Educator, and the Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 2.Patient #11 has a Start of Care date of 09/04/2024 with the following diagnoses “Pulmonary Fibrosis, Systemic Lupus Erythematosus, Malignant Neoplasm of Colon” documented on the Physicians Orders/Plan of Care for the Certification Period 09/04/2024 to 12/02/2024. The Physicians Orders/Plan of Care dated 09/04/2024 documents: AID (Hospice Home Health Aide) 09/04/2024 5 x week x 13 weeks (five times a week for thirteen weeks). The clinical record lacks documented evidence of an aide providing care for the week of: 09/15/2024 to 09/21/2024 - five missed visits. There is no documented evidence of the patient receiving aide services as ordered on the plan of care. On 10/03/2024 at 03:00 PM, the Administrator/CEO (Chief Executive Officer), the Assistant Director of QAPI (Quality Assurance and Performance Improvement)/Educator, Registered Nurse Staff Educator, and the Registered Nurse Auditor were interviewed and did not provide an explanation for the findings.”

“Based on clinical record review and staff interview the hospice failed to ensure all Hospice Aides receive complete written patient care instructions prepared by a Registered Nurse (RN). This is evident for two (2) of twenty-nine (29) clinical records reviewed (Patient # 4 and #23). Failure to ensure all Hospice Aides receive complete written patient specific care instructions prepared by a Registered Nurse (RN) has the potential for negative patient outcome. The findings are: 2.Patient #23 has a Start of Care date of 5/30/24 with diagnoses of Cerebrovascular disease, unspecified and Vascular dementia documented on the Physicians Orders/Plan of Care with a Certification Period from 5/30/2024 to 8/2720/24. The “;Hospice Home Health Aide Plan of Care and Weekly Notes,” documents the home health aide performed transfers out of bed by Hoyer lift on 9/18/2024, 9/23/2024, and 9/25/2024. There is no documented evidence of the Registered Nurse assigning the home health aide to perform transfer by Hoyer lift for 9/18/2024, 9/23/2024, and 9/25/2024 on the “;Hospice Home Health Aide Plan of Care.” On 10/03/2024 at 01:05 PM the Administrator/ CEO (Chief Executive Officer), The Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, the Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 1.Patient #4 has a Start of Care date of 07/17/2024 with the following diagnoses “Malignant Neoplasm of Prostate, Secondary and Unspecified Malignant Neoplasm of Lymph Node, Atherosclerotic Heart Disease” documented in the Physicians Orders/ Plan of Care for the Certification Period 07/17/2024 to 10/14/2024. The Physicians Orders/ Plan of Care for the Certification Period 07/17/2024 to 10/14/2024 documents: Allergies: Amoxicillin, Ciprofloxacin, Ibuprofen, Penicillin G, Procain. The Hospice Home Health Aide Plan of Care and Weekly Notes dated 07/17/2024 lacks documented evidence of the allergies and instructions of aide observations that should be reported to the supervisor. There is no documented evidence of an accurate written patient care instructions for a hospice aide to follow. On 10/04/2024 at 01:07 PM, the Administrator/ CEO (Chief Executive Officer, Assistant Director of QAPI (Quality Assurance Performance Improvement), and Education, Registered Nurse Staff Educator, and the Registered Nurse Auditor were interviewed and did not provide an explanation for the findings.”

“Based on clinical record review and staff interview the Hospice failed to ensure a competency evaluation is conducted when an area of concern or a deficient skill is identified in the aides performance. This was evident in one (1) of twenty-nine of twenty-nine (29) clinical records reviewed (Patient #23). Failure to ensure a competency evaluation is conducted when a deficient skill or an area of concern is identified in the aides performance has the potential for negative patient outcome. The findings are: Patient #23 has a Start of Care date of 5/30/2024 with diagnoses of Cerebrovascular Disease, unspecified and Vascular Dementia documented on the Physicians Orders/Plan of Care with a Certification Period from 5/30/2024 to 8/27/2024. The RN (Registered Nurse) “;Charts/Clinical Notes” with an “;Effective Date: 9/13/24” documents, “;Patient receives HHA (Home Health Aide) cluster care services through HONY (Hospice of New York). (Name of Home Health Aide) assigned to patient and needs more training with Hoyer lift and feeding with HOB (head of bed) elevated.” There is no documented evidence of the Home Health Aide completing a competency evaluation after it was identified on 9/13/2024 that the Home Health Aide needed more training with use of the Hoyer lift and feeding the patient with the head of the bed elevated. On 10/04/2024 at 01:07 PM, the Administrator the Administrator/ CEO (Chief Executive Officer), The Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, the Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings.”

“Based on clinical record review and staff interview the hospice failed to ensure that the supervising nurse assessed and ensured that all Hospice Aides followed the patient’s plan of care for completion of tasks as assigned by the Registered Nurse (RN). This is evident is for one (1) of twenty-nine (29) clinical records reviewed (Patient #4). Failure to ensure that the supervising nurse assesses and ensures that all Hospice Aides follow the patient’s plan of care for completion of tasks assigned by the Registered Nurse has the potential for negative patient outcome. The findings are: 1. Patient #4 has a Start of Care date of 07/17/2024 with the following diagnoses “Malignant Neoplasm of Prostate, Secondary and Unspecified Malignant Neoplasm of Lymph Node, Atherosclerotic Heart Disease” documented on the Physicians Orders/ Plan of Care for the Certification Period 07/17/2024 to 10/14/2024. The Hospice Home Health Aide Plan of Care and Weekly Notes documents aide services being provided on: 08/05/2024 to 08/09/2024, 08/13/2024 to 08/16/2024, 08/19/2024, 08/26/2024 to 08/29/2024, 09/03/2024 to 09/06/2024, 09/09/2024 to 09/13/2024, 09/16/2024 to 09/20/2024. The Aide supervision dated 07/24/2024, 07/30/2024, 08/05/2024, 08/15/2024, 08/22/2024, 08/28/2024, 09/06/2024, 09/11/2024, and 09/26/2024 lacks documented evidence of the nurse supervising the aide with complying with infection control policies and procedures and reporting any changes in the patients condition. On 10/04/2024 at 01:07 PM, the Administrator/ CEO (Chief Executive Officer), The Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, the Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings.”

“Based on clinical record review and staff interview the Hospice failed to ensure the content of the Hospice clinical record includes the patient’s response to medications and treatments. This was evident in one (1) of twenty-nine (29) clinical records reviewed. (Patient #2). Failure to ensure the clinical record includes the patient’s response to medications has the potential for negative outcome. The findings are: 1. Patient #2 has a Start of Care date of 07/26/2024 with the following diagnoses “Senile Degeneration of Brain, Dementia” documented in the Physicians Orders/ Plan of Care for the Certification Period 07/26/2024 to 10/23/2024. The Charts/Clinical Notes documents:07/29/2024 “;Pt (patient) appears to be agitated when touched or trying to be assessed.” “;Pt (patient) appears to be pain when we attempt to move her. Morphine 5 mg (milligram) given.”08/06/2024 “;Last bm (bowel movement) noted on 07/31. Educated pt (patient) on the use of senna syrup daily and bisacodyl after 2 days of no bm (bowel movement).”08/20/2024 “;pt (patient) screams out when touched, advised on the usage of Morphine and Lorazepam from comfort box, verbalized understanding, same ordered, fleet enemas were ordered for constipation.”08/27/2024 “;Last BM (bowel movement) was on 08/25. Educated caregiver that if pt (patient) doesnt have a bm (bowel movement) by the end of today, administer a bisacodyl suppository.” The clinical record lacks documented evidence of the responses to medications, and symptom management from 7/29/2024 to 8/27/2024. On 10/03/2024 at 01:05PM, the Administrator/ CEO (Chief Executive Officer), The Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, the Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings.”

“Based on clinical record review and staff interview, the hospice failed to instruct the patient in the safe use of and demonstrate durable medical equipment and supplies. This was evident for three (3) of twenty-nine (29) clinical records reviewed. (Patient #1, #2, and #3). Failure to instruct the patient in the safe use of durable medical equipment has the potential for negative patient outcome. The findings are: 1.Patient #1 has a Start of Care date of 01/16/2024 with the following diagnoses “Senile Degeneration of Brain, Dementia” documented in the Physicians Orders/ Plan of Care as of 09/12/2024, for the Certification of Terminal Illness Period 09/12/2024 to 11/10/2024. On 09/30/2024 at 3:30 PM a home visit was conducted. Oxygen was observed in the home. There was no sign in the home indicating oxygen is in use. There is no documented evidence of the hospice placing a sign in the home on the safe use of oxygen. On 10/03/2024 at 01:05 PM, the Administrator/ CEO (Chief Executive Officer), The Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, the Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 2.Patient #2 has a Start of Care date of 07/26/2024 with the following diagnoses “Senile Degeneration of Brain, Dementia” documented in the Physicians Orders/ Plan of Care for the Certification Period 07/26/2024 to 10/23/2024. On 10/01/2024 at 11:10 AM a home visit was conducted. Oxygen was observed in the home. There is no sign in the home indicating that oxygen is in use. There is no documented evidence of the hospice placing a sign in the home on the safe use of oxygen. On 10/03/2024 at 01:05 PM, the Administrator/ CEO (Chief Executive Officer), The Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, the Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings. 3.Patient #3 has a Start of Care date of 10/14/2023 with the following diagnoses “Senile Degeneration of Brain, Dementia” documented in the Physicians Orders/ Plan of Care as of 08/09/2024, for the Certification of Terminal Illness Period 08/09/2024 to 10/07/2024. On 10/01/2024 at 2:45 PM a home visit was conducted. Oxygen was observed in the home. There is no sign in the home indicating that oxygen is in use. There is no documented evidence of the hospice placing a sign in the home on the safe use of oxygen On 10/03/2024 at 01:05 PM, the Administrator/ CEO (Chief Executive Officer), The Assistant Director of QAPI (Quality Assurance and Performance Improvement) / Education, the Registered Nurse Staff Educator, and Registered Nurse Auditor were interviewed and did not provide an explanation for the findings.”