Caring Hospice Services of New York, LLC

“Based on clinical record reviews and staff interviews, the Hospice failed to ensure all patient receive effective pain management. This was evident for one (1) of nineteen (19) clinical records reviewed (Patient #13). Failure to ensure that all patient receive effective pain management has the potential for negative patient outcome. The findings are: 1. Patient #13 has a Start of Care date of 04/16/2024 with the following diagnoses “Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung, Post-Traumatic Stress Disorder, Status Post Kidney Transplant” documented in the Hospice Plan of Care dated 04/18/2024. The Nursing Comprehensive Reassessment documents: 04/19/2024 and 04/26/2024 Pain level now: 0; Worst pain level experienced: 5; Pt (patient) has mild to moderate general pain and back pain, and he is taking Oxycodone 10mg (milligram) q8h PRN (every eight hours as needed) and Acetaminophen 500mg 2 tabs q8h (tablets every eight hours) to manage pain. Pt (patient) stated that he is mostly comfortable. “;Pt (patient) has trouble turning body and exchange cloth due to increased pain but pt (patient) refused to increase dosage of pain meds.”05/02/2024 Pain level now: 0; Worst pain level experienced: 10; Pt (patient) reports he wakes up in the middle of the night frequently due to pain, had difficulty staying asleep; Current pain management and effectiveness: takes 10mg (milligram) Oxycodone and Tylenol, reports that pain is temporary relieved from medication but never gets rid of the pain. Breakthrough pain: daily. “;Pt (patient) has moderate to severe general pain and back pain” “;Pt (patient) stated pain rating 2/10 during visit. Pt (patient) reports pain interferes with ADLs (activity of daily living). Pt (patient) wanting pain to be more under control but not sure what will help as he has tried everything. Pt (patient) is afraid of side effects of pain medications (kidney dysfunction, constipation, drowsiness). Pt (patient) open to adjustments to regimen. Pt (patient) reports carpal tunnel pain in L (left) wrist, pt (patient) states this is pain began years ago but now feels worse.” The IDG Meeting Review/Plan of Care with Medical Doctor documents: “04/17/2024 and 04/24/2024 Pt. (patient) has mild to moderate general pain and back pain, and he is taking Oxycodone 10mg (milligram) q8h (every eight hours) PRN (as needed) and Acetaminophen 500mg (milligram) 2 tabs (tablets) q8h (every eight hours) to manage pain, pt (patient) stated that he is mostly comfortable. 05/02/2024 Pt (patient has moderate to severe general pain and back pain, and he is taking Oxycodone 10mg (milligram) q8h (every eight hours) PRN (as needed) and Acetaminophen 500mg (milligram) 2 tabs (tablets) q8h (every eight hours) to manage pain, pt (patient) stated pain rating 2/10 during visit. Pt (patient) reports pain interferes with ADLS (activities of daily living). Pt (patient) wanting paint ot be more under control but not sure what will help as ‘he has tried everything’. Pt (patient) is afraid of side effects of pain medications (kidney dysfunction, constipation, drowsiness). Pt (patient) open to adjustments to regimen.” There is no documented evidence of a new intervention to manage pain. There is no documented evidence that the patient received effective pain management from the hospice. On 05/23/2023 at 02:35pm, the Administrator/Director of Patient Services, and the Clinical Managers were interviewed and did not provide an explanation for the findings.”

“Based on clinical record reviews and staff interviews, the Hospice failed to ensure that each patient and their primary care givers receive education and training for the care and services identified in the plan of care. This was evident for one (1) of nineteen (19) clinical records reviewed (Patient #12). Failure to ensure that the primary care givers receive education and training for the care and services identified in the plan of care has the potential for negative patient outcome. The findings are: 1. Patient #12 has a Start of Care date of 09/06/2023 with the following diagnoses “Malignant Neoplasm of Biliary Tract, Secondary Malignant Neoplasm of Liver and Intrahepatic Bile Duct” documented in the IDG Meeting Review/ Plan of Care dated 05/08/2024, certification period 05/03/2024 to 07/01/2024. The IDG Meeting Review/ Plan of Care dated 05/08/2024 documents: Medications: Oxygen inhalation 2l/m (two liters per minute) PRN/as needed SOB (shortness of breath); Diet: Pureed Diet. The Nursing Comprehensive Reassessment documents:05/06/2024 Soft Mech (mechanical) diet; Summary: uses oxygen 4-5x (four to five times) a day at 6-8 L/M (six to eight liters per minute) via NC PRN (nasal cannula as needed);05/13/2024 and 05/20/2024 Soft Mech (mechanical) diet. There is no documented evidence that the primary care giver was educated in providing the care that is written in the plan of care – care giver providing mechanical soft diet and giving oxygen 6-8 liters per minute, but the plan of care is diet puree and oxygen 2 liters per minute. On 05/22/2023 at 02:03pm, the Administrator/Director of Patient Services, and the Clinical Managers were interviewed and did not provide an explanation for the findings.”

“Based on clinical record reviews and staff interviews, the Hospice failed to ensure that the individualized plan of care reflect the goals and interventions based on the problems identified. This was evident for two (2) of nineteen(19) clinical records reviewed (Patients #1 and #2). Failure to ensure that the individualized plan of care reflect the goals and interventions based on the problems identified has the potential for negative patient outcome. The findings are: 1. Patient #1 has a Start of Care date of 05/10/2024 with diagnosis Malignant Neoplasm of Connective and Soft Tissue documented in the Plan of Care dated 05/10/2024 to 07/08/2024. The Physician Order dated 05/10/2024 documents verbal order for spiritual care counseling (SCC)/Chaplain visits: one visit a month for two months starting 05/10/2024 (week 1). The initial Spiritual Care Assessment dated 05/10/2024 documents the patient and family spiritual care goals and interventions. The individualized Hospice Plan of Care for benefit period 05/10/2024 to 07/08/2024, signed by the Physician/Medical Director on 05/20/2024, lacks documented evidence of the spiritual care interventions and goals established on 05/10/2024. On 05/22/2024 at 2:00 pm, the Administrator/Program Director and the Patient Clinical Managers were interviewed and did not provide an explanation for the finding. 2. Patient #2 has a Start of Care date of 03/30/2024 with diagnosis Heart Failure documented in the Hospice Plan of Care for benefit period 03/30/2024 to 06/27/2024. The Physician Order dated 04/01/2024 documents: “;O2 (Oxygen) at 2-5L(Liters/min(minute) via NC (Nasal Cannula) PRN (as needed) for SOB (shortness of breath).” The Hospice Nursing Initial Comprehensive Admission Assessment dated 03/30/2024 documents for respiratory assessment: “Shortness of breath level now: 0 (none); best level experience: 0; worst level experience: 4.” The “;Equipment Request” dated 04/01/2024 documents: “O2 5 Liters (flowrate unknown) RUSH (delivery); and Nasal Cannula were ordered and delivered on 04/01/2024 to the patients home.” The Nursing Comprehensive Reassessment dated 04/01/2024 documents: “;Shortness of breath improved by: O2 2L(liters)/min (minute) via nasal cannula” as needed. The initial Medical Social Services Assessment dated 04/02/2024 documents: “;Patient is not oxygen dependent. Oxygen Concentrator is available in the event patient experience SOB (shortness of breath).” The individualized Hospice Plan of Care for benefit period 03/30/2024 to 06/27/2024, signed by the Physician/Medical Director on 04/17/2024, lacks documented evidence of the interventions and goals for respiratory- shortness of breath. On 05/22/2024 at 2:00 pm, the Administrator/Program Director and the Patient Clinical Managers were interviewed and did not provide an explanation for the finding.”

“Based on clinical record reviews and staff interviews, the Hospice failed to ensure that the individualized plan of care must include interventions to manage pain and symptoms. This was evident for two (2) of nineteen(19) clinical records reviewed (Patients #3 and #13). Failure to ensure that the individualized plan of care must include interventions to manage pain and symptoms has the potential for negative patient outcome. The findings are: 2. Patient #13 has a Start of Care date of 04/16/2024 with the following diagnoses “Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung, Post-Traumatic Stress Disorder, Status Post Kidney Transplant” documented in the Hospice Plan of Care dated 04/18/2024. The Nursing Comprehensive Reassessment documents:04/19/2024 and 04/26/2024 Pain level now: 1; Worst pain level experienced: 5; “;Pt (patient) has mild to moderate general pain and back pain, and he is taking Oxycodone 10mg (milligram) q8h PRN (every eight hours as needed) and Acetaminophen 500mg 2 tabs q8h (tablets every eight hours) to manage pain. Pt (patient) stated that he is mostly comfortable.” “;Pt (patient) has trouble turning body and exchange cloth due to increased pain but pt (patient) refused to increase dosage of pain meds.”05/02/2024 Pain level now: 0; Worst pain level experienced: 10; “;Pt (patient) reports he wakes up in the middle of the night frequently due to pain, had difficulty staying asleep; Current pain management and effectiveness: takes 10mg (milligram) Oxycodone and Tylenol, reports that pain is temporary relieved from medication but never gets rid of the pain.” Breakthrough pain: daily; “;Pt (patient) has moderate to severe general pain and back pain” “;Pt (patient) stated pain rating 2/10 during visit. Pt (patient) reports pain interferes with ADLs (activity of daily living). Pt (patient) wanting pain to be more under control but not sure what will help as he has tried everything. Pt (patient) is afraid of side effects of pain medications (kidney dysfunction, constipation, drowsiness). Pt (patient) open to adjustments to regimen. Pt (patient) reports carpal tunnel pain in L (left) wrist, pt (patient) states this is pain began years ago but now feels worse.” There is no documented evidence of a new intervention to manage pain including use of alternative therapies like heat/cold, massage, etc. There is no documented evidence of an effective pain management. On 05/23/2023 at 02:35pm, the Administrator/Director of Patient Services, and the Clinical Managers were interviewed and did not provide an explanation for the findings. Patient #3 has a Start of Care date of 02/29/2024 with diagnosis Malignant Neoplasm of Cervix Uterine documented in the Hospice Plan of Care for benefit period 02/29/2024 to 05/28/2024. The Hospice Nursing Initial Comprehensive Admission Assessment dated 02/29/2024 documents: “;Mild sacrum pain is present occasionally due to stage 3 bedsore. Pt (Patient) doesnt use any pain meds (medications) now; able to handle her sacrum discomfort.” The Hospice Plan of Care for benefit period 02/29/2024 to 05/28/2024 documents the following: Pain - “;Pt has sacrum mild pain due to bedsore;” “;(patient) doesnt use any pain meds. CP (Comfort Pak) with morphine was ordered for potential pain/sob (shortness of breath;” Medications - “;CP (Comfort Pak) Morphine Sulfate Oral Concentrate, 100mg/5ml (20 mg/ml), Dispense 15 ml, Oral 0.25 ml q4h (every four hours) prn (as needed) pain/sob,” Effective Date: 02/29/2024;” and “;Acetaminophen 650mf suppositories, four suppositories rectal, 1 sup q6h prn fever,” Effective Date: 02/29/2024.” The Plan of Care documents one medication for pain. The Nursing Comprehensive Reassessment dated 03/04/2024 documents: “;No pain on assessment. Acetaminophen 650 mg and Morphine 0.25 ml are available for potential episodes of pain; and “;Current pain management and effectiveness: Acetaminophen 650 mg Q6hrs (every six hours) PRN (as needed) for potential episodes of pain.” The Nursing Comprehensive Reassessment dated 03/15/2024 documents: “;Patient has dull and aching generalized occasional pain which effectively managed with Tylenol 350mf 2 tablets daily PRN. No pain or discomfort was noted/verbalized during the visit.” The clinical record lacks documented evidence of an order to use Acetaminophen (Tylenol) for pain. The Hospice Plan of Care lacks documented evidence including all medications the patient uses for effective pain management. On 05/23/2024 at 2:30 pm, the Administrator/Program Director and the Patient Clinical Managers were interviewed and did not provide an explanation for the finding.”

“Based on clinical record reviews, policy and procedures review, and staff interviews, the Hospice failed to ensure that the individualized plan of care must include drugs and treatment necessary to meet the needs of the patient. This was evident for two (2) of nineteen(19) clinical records reviewed (Patients #11, and #15). Failure to ensure that the individualized plan of care must include drugs and treatment necessary to meet the needs of the patient has the potential for negative patient outcome. The findings are: 1. Patient #11 has a Start of Care date of 10/13/2023 with the following diagnoses “Senile Degeneration of Brain, Hemiplegia following Cerebral Infraction” documented in the IDG Meeting Review/ Plan of Care dated 04/10/2024, certification period 04/10/2024 to 06/08/2024. The IDG Meeting Review / Plan of Care dated 05/08/2024 documents: Insulin Lispro subcutaneous sliding scale four times per day. The Nursing Comprehensive Reassessment documents: “05/20/2024: 05/14/24 doctor DC (discontinued) FS (fingerstick).” There is no documented evidence of the physician order to discontinue fingerstick and Insulin Lispro. On 05/23/2023 at 02:35pm, the Administrator/Director of Patient Services, and the Clinical Managers were interviewed and did not provide furthern explanation for the findings. 2. Patient #15 has a Start of Care date of 03/14/2024 with the following diagnoses “Atherosclerotic Heart Disease of Native Coronary Artery, Coronary Artery Dissection” documented in the Hospice Plan of Care dated 03/15/2024. The Hospice Nursing Initial Comprehensive Admission Assessment dated 03/14/2024 and the Hospice Nursing Clinical Note dated 03/15/2024 documents: “;HTN (hypertension) is managed with Amlodipine 5mg (milligram) daily.” The Nursing Comprehensive Reassessment dated 03/19/2024, 03/26/2024, 04/04/2024, 04/09/2024, 04/17/2024, 04/24/2024, 04/29/2024, 05/10/2024, and 05/17/2024 documents: “;Inhalation treatments: “;Duoneb q 4 (every four) hours via Nebulizer PRN (as needed) for SOB (shortness of breath).” “;HTN (hypertension) is managed with Amlodipine 5mg (milligram) daily.” The Hospice Medication Profile and Plan of Care for the Certification Period from 03/14/2024 to 06/11/2024 lacks documented evidence of physician order for Amlodipine and Duoneb. On 05/23/2023 at 02:35pm, the Administrator/Director of Patient Services, and the Clinical Managers were interviewed and did not provide an explanation for the findings.”

“Based on clinical record reviews, policy and procedures review, and staff interviews, the Hospice failed to ensure that the individualized plan of care includes medical supplies and appliances necessary to meet the needs of the patient. This was evident for one (1) of nineteen(19) clinical records reviewed (Patient #16). Failure to ensure that the individualized plan of care include medical supplies and appliances necessary to meet the needs of the patient has the potential for negative patient outcome. The findings are: 1. Patient #16 has a Start of Care date of 01/18/2024 with the following diagnoses “Malignant Neoplasm of Esophagus, Type 2 Diabetes Mellitus, Malignant Ascites” documented in the Hospice Plan of Care dated 01/22/2024. The Hospice Nursing Initial Comprehensive Admission Assessment dated 01/18/2024 documents: “Assistive device(s) used: CANE, W/C (wheelchair).” The Hospice Aide Assignment dated 01/19/2024 documents: “Diet: Peg-tube fed; w/c (wheelchair), cane, use of shower chair, raised toilet seat.” The Medical Social Services Assessment dated 01/22/2024 documents: “;Patient is able to ambulate at home with a walker” “;Oxygen concentrator is available for patients use.” The Hospice Plan of Care lacks documented evidence of the following DME (durable medical equipment): wheelchair, cane, shower chair, raised toilet seat, walker, and oxygen concentrator. On 05/23/2023 at 02:35pm, the Administrator/Director of Patient Services, and the Clinical Managers were interviewed and did not provide an explanation for the findings.”

“Based on clinical record review and staff interviews, the hospice failed to ensure that the Interdisciplinary Group (IDG) reviewed and revised the individualized Plan of Care (POC) as the patient’s care needs changes, but no less frequently than every fifteen (15) days. This was evident for six (6) of nineteen (19) clinical records reviewed (Patients #2, #3, #5, #9, #12, and #13). Failure to ensure the IDG (Interdisciplinary Group) review and revise the Plan of Care has the potential for negative patient outcome. The findings are: 5. Patient #12 has a Start of Care date of 09/06/2023 with the following diagnoses “Malignant Neoplasm of Biliary Tract, Secondary Malignant Neoplasm of Liver and Intrahepatic Bile Duct” documented in the IDG Meeting Review/ Plan of Care dated 05/08/2024, certification period 05/03/2024 to 07/01/2024. The IDG Meeting Review/ Plan of Care dated 05/08/2024 documents: Uses oxygen 4-5x (times) a day at 6-8 L/M (liters per minute) via NC PRN (nasal cannula as needed); Medications: Oxygen inhalation 2l/m (two liters per minute) PRN/as needed SOB (shortness of breath); Diet: Pureed Diet. The Nursing Comprehensive Reassessment documents:05/06/2024 Soft Mech (mechanical) diet; Summary: uses oxygen 4-5x (four to five times) a day at 6-8 L/M (six to eight liters per minute) via NC PRN (nasal cannula as needed);05/13/2024 and 05/20/2024 Soft Mech (mechanical) diet. The clinical record lacks documented evidence of the plan of care being reviewed and revised – care giver providing mechanical soft diet and oxygen 6-8 liters per minute, but the plan of care documents diet puree and oxygen 2 liters per minute. On 05/22/2023 at 02:03pm, the Administrator/Director of Patient Services, and the Clinical Managers were interviewed and did not provide an explanation for the findings. 6. Patient #13 has a Start of Care date of 04/16/2024 with the following diagnoses “Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung, Post-Traumatic Stress Disorder, Status Post Kidney Transplant” documented in the Hospice Plan of Care dated 04/18/2024. The Hospice Plan of Care dated 04/18/2024 documents: Hha (home health aide): 2 x (two times) week for 14 weeks starting 04/18/2024. The Nursing Comprehensive Reassessment dated 05/02/2024 and 05/17/2024 documents: (Name of caregiver) and patient are open to trying Hha (home health aide) a few times a week. Pt (patient) said he previously refused HHA (home health aide) but now is more open.” The Medical Social Services Clinical Note dated 05/16/2024 documents: “;Pt (patient) also declines 20hrs (hours) with Caring Hospice Services.” “;Pt (patient) and CG (caregiver) discussed HHA (home health aide) options and pt (patient) stated that he doesnt want strangers caring for him.” The IDG Meeting / Plan of Care dated 04/24/2024, 05/08/2024, and 05/22/2024 documents: Hha (home health aide): 2 x (times) week for 14 weeks starting 04/18/2024. There is no documented evidence of aide providing services from 04/18/2024 to present. There is no documented evidence that the IDG reviewed and revised the plan of care to discontinue hospice aide or change visit frequency. On 05/23/2023 at 02:35pm, the Administrator/Director of Patient Services, and the Clinical Managers were interviewed and did not provide an explanation for the findings. 4.Patient #9 has a Start of Care date of 02/10/2024 with the following diagnoses “Senile Degeneration of Brain, Hypertensive Heart Disease with Heart Failure, Primary Open-Angle Glaucoma” documented on the Hospice Plan of Care for the Certification Period 02/10/2024 to 05/09/2024. The Nursing Comprehensive Reassessment dated 04/22/2024, 04/29/2024, 05/06/2024 documents: “;Integumentary Section: Wound#1 Stage: Stage 2 Pressure Ulcer/Injury.” The IDG (Interdisciplinary Group) Meeting Review/Plan of Care dated 04/24/2024, 05/01/2024 and 05/08/2024 documents: “;Integumentary: Summary of Problems: Patient has Sacrum stage 1 Pressure Ulcer.” The Physician Order dated 05/06/2024 documents:” SSD (Silver Sulfadiazine) Cream 1% Apply twice per day wound Start Effective Date:05/06/2024.” The IDG (Interdisciplinary Group) Plan of Care dated 05/08/2024 documents:” Integumentary Interventions: Cleanse with: NS (Normal Saline); Dress with: Zinc Oxide; 6*6 DPD (Dry, Protective Dressing); Start Effective Date:02/10/2024.” The IDG (Interdisciplinary Group) Plan of Care dated 04/24/2024, 05/01/2024 and 05/08/2024 lack documented evidence of being updated regarding the patients wound status, and current wound interventions on 05/08/2024. On 05/22/2024 at 03:00 pm, the Administrator/Program Director and the Patient Clinical Managers were interviewed and did not provide an explanation for the finding. Patient #2 has a Start of Care date of 03/30/2024 with diagnosis Heart Failure documented in the Hospice Plan of Care for benefit period 03/30/2024 to 06/027/2024. The Hospice Plan of Care for benefit period 03/30/2024 to 06/27/2024 documents the following orders for SCC (Spiritual Care Counseling)/Chaplain visit frequency: “;1 x month for 4 months starting 03/30/2024 (week 1);” and two as needed visits starting 03/30/2024 for support. The Chaplain “Spiritual Care Narrative Note” dated 04/03/2024 documents: “Chaplain attempted to schedule visit. As per pts (patients) (family member), patient is declining visit at this time Chaplain will remain available upon request for (future) spiritual care support.” The IDG (Interdisciplinary group) Meeting Review/Plan of Care 04/03/2024, 04/10//2024, 04/24/2024, and 05/08/2024 document SCC (Spiritual Care Counseling)/Chaplain as an “;active (visit) frequencies”/service: “;1 x month (one visit a month) for 4 months starting 03/30/2024 (week 1).” The clinical record lacks documented evidence of the Plan of Care being reviewed and revised to discontinue Spiritual Care Counseling/Chaplain services/visit frequency in accordance with the patients request. The Hospice Plan of Care for benefit period 03/30/2024 to 06/27/2024 documents the following orders for hospice aide/home health aide visit frequency: “;3 x week (three visits a week) for 13 weeks starting 04/02/2024 (week 2): State Date: 04/02/024, End Date: 06/27/2024.” The Nursing Comprehensive Reassessment note dated 04/17/2024 documents: “;Patient/Caregiver feels (home health aide) is not needed as this time. (Home health aide) services discontinued as of 4/17/24.” The IDG (Interdisciplinary Group) Meeting Review/Plan of Care 04/24/2024, and 05/08/2024 document home health aide as active (visit) frequencies: “3 x week (three visits a week) for 13 weeks.” The clinical record lacks documented evidence of the Plan of Care being reviewed and revised to discontinue hospice aide/home health aide services/visit frequency in accordance with the patients request. 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 05/22/2024 at 2:00 pm, the Administrator/Program Director and the Patient Clinical Managers were interviewed and did not provide an explanation for the finding. Patient #3 has a Start of Care date of 02/29/2024 with diagnosis Malignant Neoplasm of Cervix Uterine documented in the Hospice Plan of Care for benefit period 02/29/2024 to 05/28/2024. The Hospice Plan of Care for benefit period 02/29/2024 to 05/28/2024 documents the following: Pain - “;Pt has sacrum mild pain due to bedsore;” “;(patient) doesnt use any pain meds. CP (Comfort Pak) with morphine was ordered for potential pain/sob (shortness of breath;” Medications - “;CP (Comfort Pak) Morphine Sulfate Oral Concentrate, 100mg/5ml (20 mg/ml), Dispense 15 ml, Oral 0.25 ml q4h (every four hours) prn (as needed) pain/sob,” Effective Date: 02/29/2024;” and “;Acetaminophen 650mf suppositories, four suppositories rectal, 1 sup q6h prn fever,” Effective Date: 02/29/2024.” The Plan of Care documents one medication for pain. The IDG(Interdisciplinary Group) Meeting Review/Plan of Care dated 03/27/2024, 04/10/2024, 04/24/2024, 05/08/2024 and 05/15/2024 document: Meeting Notes: “;patient has dull and aching generalized occasional pain which (is) effectively managed with Tylenol (Acetaminophen) 325mg, 2 Tablets daily, PRN (as needed).” There is no documented evidence of the Interdisciplinary Group reviewing and revising the patients plan of care for pain management to include Tylenol (Acetaminophen) . The Hospice Plan of Care for benefit period 02/29/2024 to 05/28/2024 documents the following orders for SCC (Spiritual Care Counseling)/Chaplain visit frequency: “;1 x month for 4 months Starting 02/29/2024 (week 1);” and three as needed visits starting 02/29/2024 for support. The Chaplain “Spiritual Care Narrative Note” dated 02/29/2024 documents: “TC (Telephone call) to pts (patients) (Family member). As per pts (patients) (family member), chaplain visit will to be proponed. Chaplain will reattempt to in several weeks.” The Chaplain “Spiritual Care Narrative Note” dated 03/12/2024 documents: “;Chaplain reattempt to visit pt(patient). As per pts (patients) (family member), chaplain visit is further postponed to following week.” The clinical record lacks documented evidence of the Chaplain making another attempt to schedule a visit. The IDG (Interdisciplinary Group) Meeting Review/Plan of Care dated 03/27/2024, 04/10/2024, 04/24/2024, 05/08/2024 and 05/15/2024 document SCC (Spiritual Care Counseling)/Chaplain as an “;active (visit) frequencies”/service: “;1 x month (one visit a month) for 4 months starting 02/29/2024 (week 1).” The clinical record lacks documented evidence of the Plan of Care being reviewed and revised for Spiritual Care Counseling/Chaplain service/visit frequency in accordance with the patients request/needs. On 05/23/2024 at 2:30 pm, the Administrator/Program Director and the Patient Clinical Managers were interviewed and did not provide an explanation for the finding. Patient #5 has a Start of Care date of 03/09/2024, Discharge Date of 04/27/2024, with diagnoses Chronic Obstructive Pulmonary Disease, Anxiety Disorder, Major Depression, Respiratory Failure Unspecified with Hypoxia, documented in the Hospice Plan of Care for benefit period 03/09/2024 to 06/06/2024. The Hospice Plan of Care for benefit period 03/09/2024 to 06/06/2024 documents: patients “;diet/hydration; NPO (nothing by mouth);” and “;No PO (by mouth) intake, mouth care only.” The Nursing Comprehensive Reassessment dated 03/19/204 documents: “;Meeting Notes: Pleasure feeding. Just last week, patient had no PO (by mouth) intake. Today (patient) is able to consume a small amount of puree consistence meal and some fluids. Aspiration precaution in place.” The IDG (Interdisciplinary Group) Meeting Review/Plan of Care dated 03/27/2024 documents in Meeting Notes section the nursing note on 03/19/2024 regarding the update in patients diet needs - “;(patient) is able to consume a small amount of puree consistence meal and some fluids.. The clinical record lacks documented evidence of the Plan of Care being reviewed and revised regarding the change in the patient’s diet. On 05/24/2024 at 1:15 pm, the Administrator/Program Director and the Patient Clinical Managers were interviewed and did not provide an explanation for the finding.”

“Based on clinical record reviews and staff interviews, the Hospice failed to ensure that services are provided in accordance with the Plan of Care. This was evident for six (6) of nineteen(19) clinical records reviewed (Patients #3, #8, #9, #12, #13, and #14). 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 #12 has a Start of Care date of 09/06/2023 with the following diagnoses “Malignant Neoplasm of Biliary Tract, Secondary Malignant Neoplasm of Liver and Intrahepatic Bile Duct” documented in the IDG Meeting Review/ Plan of Care dated 05/08/2024; certification period 05/03/2024 to 07/01/2024. The IDG Meeting Review/ Plan of Care dated 05/08/2024 documents: Uses oxygen 4-5x (times) a day at 6-8 L/M (liters per minute) via NC PRN (nasal cannula as needed); Medications: Oxygen inhalation 2l/m (two liters per minute) PRN/as needed SOB (shortness of breath). The clinical record lacks documented evidence of the Registered Nurse communicating with the physician - patient using oxygen 6-8 liters and plan of care is oxygen 2 liters; and the need to change the plan of care. There is no documented evidence that the services are being provided in accordance with the plan of care. On 05/23/2023 at 02:35pm, the Administrator/Director of Patient Services, and the Clinical Managers were interviewed and did not provide an explanation for the findings. 4. Patient #13 has a Start of Care date of 04/16/2024 with the following diagnoses “Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung, Post-Traumatic Stress Disorder, Status Post Kidney Transplant” documented in the Hospice Plan of Care dated 04/18/2024. The Hospice Plan of Care dated 04/18/2024 documents: Hha (home health aide): 2 x (two times) week for 14 weeks starting 04/18/2024. The clinical records lack documented evidence of aide services being provided on 04/18/2024 to present. There is no documented evidence that the services are being provided in accordance with the written plan of care. On 05/23/2023 at 02:35pm, the Administrator/Director of Patient Services, and the Clinical Managers were interviewed and did not provide an explanation for the findings. 5. Patient #14 has a Start of Care date of 04/02/2023 with the following diagnoses “Senile Degeneration of Brain, Type 2 Diabetes Mellitus” documented in the Hospice Plan of Care dated 04/04/2024. The Hospice Plan of Care dated 04/04/2024 documents: “;HHA (home health aide) 5 x (times) week for 14 weeks starting 04/03/2024;” “;SCC (spiritual care counselling) / Chaplain: 2 x (times) month for 3 months starting 04/03/2024.” The clinical records documents spiritual care visit on 04/03/20224. There is no documented evidence of a spiritual care counselling visit, missed one visit for the month of April. The clinical records documents aide services being provided on 04/04/20224 and 04/05/2024. There is no documented evidence of an aide providing services, missed three visits for the week of 04/03/2024 to 04/06/2024. There is no documented evidence that the services are being provided in accordance with the plan of care. On 05/23/2023 at 02:35pm, the Administrator/Director of Patient Services, and the Clinical Managers were interviewed and did not provide an explanation for the findings. 2.Patient #8 has a Start of Care date of 03/08/2024 with the following diagnoses “Other Cirrhosis of Liver, Acute on Chronic Systolic (Congestive) Heart Failure, Essential (Primary) Hypertension” documented on the Hospice Plan of Care for the Certification Period 03/08/2024 to 06/05/2024. The Hospice Plan of Care for the Certification Period 03/08/2024 to 06/05/2024 documents: “;Stage 2 Pressure Ulcer Cleanse with: Warm water; Dress with: Silvadene; Cover with 6 x 6 DPD (Dry, Protective Dressing) Start Effective Date: 03/08/2024.” The Nursing Comprehensive Reassessment dated 03/25/2024, 04/09/2024, 04/15/2024, 04/22/2024, 04/29/2024, 05/02/2024, 05/06/2024 and 05/13/2024 documents: “;Stage 2 Pressure Ulcer Integumentary Intervention: Cleanse with wound spray, dress with Zinc Oxide, cover with 6x6 DPD (Dry, Protective Dressing).” There is no documented evidence of an interim order to discontinue Silvadene wound treatment. The clinical record lacks documented evidence of the skilled nurse providing care and services in accordance with the plan of care. On 05/24/2024 at 03:30 pm, the Administrator/Program Director and the Patient Clinical Managers were interviewed and did not provide an explanation for the finding. 3. Patient #9 has a Start of Care date of 02/10/2024 with the following diagnoses “Senile Degeneration of Brain, Hypertensive Heart Disease with Heart Failure, Primary Open-Angle Glaucoma” documented on the Hospice Plan of Care for the Certification Period 02/10/2024 to 05/09/2024. The Hospice Plan of Care for the Certification Period 02/10/2024 to 05/09/2024 documents: “;SCC (Spiritual Care Coordinator)/Chaplain 1 x month for 4 months starting 02/11/2024 Start date:02/11/2024 End Date:05/09/2024.” The clinical records documents SCC (Spiritual Care Coordinator)/Chaplain visits on 02/12/20224 and 04/01/2024. There is no documented evidence of a SCC (Spiritual Care Coordinator)/Chaplain visit between 02/12/2024 and 04/01/2024(one missed visit). There is no documented evidence of the patient receiving SCC (Spiritual Care Coordinator)/Chaplain services in accordance with the Plan of Care. On 05/24/2024 at 03:30 pm, the Administrator/Program Director and the Patient Clinical Managers were interviewed and did not provide an explanation for the finding. Patient #3 has a Start of Care date of 02/29/2024 with diagnosis Malignant Neoplasm of Cervix Uterine documented in the Hospice Plan of Care for benefit period 02/29/2024 to 05/28/2024. The Hospice Plan of Care for benefit period 02/29/2024 to 05/28/2024 documents: Medications - “;Silver Sulfadiazine (SSD) 1% External thin layer Daily (for) bed sore, Effective Date: 03/29/2024;” Integumentary – “;Stage 3 PU (pressure ulcer) present on sacrum area SSD (Silver Sulfadiazine) cream was ordered for sacrum wound care;” “;Responsible for wound care: Caregiver, Hospice Nurse;” The Nursing Comprehensive Reassessment dated 05/09/2024 documents: “;Patient has PU (pressure ulcer) stage 3 on sacrum healed completely/“ The clinical record lacks documented evidence of the Registered Nurse communicating with the physician and obtaining an order to discontinue the wound care. The clinical record lacks documented evidence of coordination of care for the patients wound care needs. The Hospice Plan of Care for benefit period 02/29/2024 to 05/28/2024 documents: Medications “;Oxygen n/c (nasal cannula) 3L PRN as need (for) sob (shortness of breath), Effective Date: 02/29/2024;” Skilled Nurse to “;assess respiratory status.” The Hospice Nursing Initial Comprehensive Admission Assessment dated 02/29/2024 documents: “;No SOB (shortness of breath) was noted. Breathing unlabored. O2 (Oxygen) sat (saturation) is 95% RA (room air). O2 concentrator ordered. The Nursing Comprehensive Reassessments dated 03/04/2024, 03/15/2024, 03/19/2024, 03/28/2024, 04/04/2024, 04/09/2024, 04/18/2024, 04/23/2024, 05/02/2024, 05/09/2024 document: “no shortness of breath observed during visit” and patient uses Oxygen 2L(liter)/min (minute) via nasal cannula PRN (as needed) for shortness of breath. The Plan of Care lacks documented evidence of an order for the patient’s use of Oxygen two (2) liters via nasal cannula as needed. The clinical record lacks documented evidence of coordination of care for the patients use of oxygen for shortness of breath. On 05/23/2024 at 2:30 pm, the Administrator/Program Director and the Patient Clinical Managers were interviewed and did not provide an explanation for the finding.”

“Based on clinical record reviews and interviews the hospice failed to ensure that all Hospice Aides received complete and accurate written patient care instructions prepared by a Registered Nurse who is responsible for the supervision of the aide. This is evident for three (3) of nineteen(19) clinical records reviewed (Patients #2, #11, and #14). Failure to ensure that all Hospice Aides receive complete and accurate written patient care instructions prepared by a Registered Nurse who is responsible for the supervision of the aide, has the potential for negative patient outcomes. The findings are: Patient #11 has a Start of Care date of 10/13/2023 with the following diagnoses “Senile Degeneration of Brain, Hemiplegia following Cerebral Infraction” documented in the IDG Meeting Review/ Plan of Care dated 04/10/2024, certification period 04/10/2024 to 06/08/2024. The IDG Meeting Review/ Plan of Care dated 04/10/2024 documents: Respiratory Oxygen nc (nasal cannula) 2l/min (two liters per minute) PRN/ as needed SOB (shortness of breath); Musculoskeletal/Activities PT (patient) bedbound/chairbound, daily placed in a wheelchair. The Nursing Comprehensive Reassessment dated 04/07/2024, 04/19/2024, 04/26/2024, 05/02/2024, 05/09/2024, 05/16/2024, and 05/20/2024 documents: Oxygen at 2 L/min (liter per minute) PRN (as needed); Bedbound; Ambulation: Total dependence; Transfer: Total dependence; Totally bed bound. The Hospice Aide Assignment dated 04/02/2024 documents: Bedbound; Ambulate only with assistance. The Hospice Aide Visit Note documents task being provided: Assist with ambulation on 04/10/2024, 04/12/2024, 04/15/2024, 04/16/2024 to 04/19/2024, 04/22/2024 to 04/26/2024, and 04/29/2024 to 05/03/2024. There is no documented evidence of an accurate and complete written patient care instructions for a hospice aide – totally bedbound on the assessment but assist with ambulation in the aides plan of care, and on oxygen. There is no documented evidence of an adequate aide supervision by the registered nurse - aides are assisting patient with walking, but totally bedbound as per the assessment. On 05/22/2023 at 02:03pm, the Administrator/Director of Patient Services, and the Clinical Managers were interviewed and did not provide an explanation for the findings. Patient #14 has a Start of Care date of 04/02/2023 with the following diagnoses “Senile Degeneration of Brain, Type 2 Diabetes Mellitus” documented in the Hospice Plan of Care dated 04/04/2024. The Hospice Plan of Care dated 04/04/2024 documents: “;Allergies: Bactrim, Penicillin.”; “;On oxygen 2L (liter) PRN (as needed).” “;HHA (home health aide): 5 x (times) week for 14 weeks starting 04/03/2024.” The Hospice Nursing Initial Comprehensive Admission Assessment dated 04/02/2024 documents: “;Genitourinary: Incontinent; Ambulation: Total Dependence; Transfer: Total Dependence; Toileting: Total dependence; Pt (patient) is weak, and frail, and generalized muscle waste is present. Chair bound and need total care.” The Nursing Comprehensive Reassessment dated 04/04/2024, 04/11/2024, 04/18/2024, 04/23/2024, 05/01/2024, 05/07/2024, and 05/14/2024 documents: “;Genitourinary: Incontinent; Bedbound; Ambulation: Total Dependence; Transfer: Total Dependence; Toileting Total dependence; Pt (patient) is weak, and frail, and generalized muscle waste is present. Patient is bedbound requires total care for all ADLs (activities of daily living).” The Hospice Aide Assignment dated 04/04/2024 documents: Allergies: NKA (no known allergy); Oxygen use: as needed for SOB (shortness of breath); Task: Assist with ambulation daily. There is no documented evidence of a complete written patient care instructions for the hospice aide – with allergies, on oxygen at 2 liters per minute, non-ambulatory, needs assistance with toileting and transfer. The Hospice Aide Visit Note documents task assist with ambulation on 04/04/2024, 04/05/2024, 04/08/2024 to 04/12/2024, 04/15/2024 to 04/19/2024, 04/22/2024 to 04/25/2024, 04/29/2024 to 05/03/2024. There is no documented evidence of an adequate aide supervision by the registered nurse - aides are assisting patient with walking, but bedbound as per the assessment. On 05/23/2023 at 02:35pm, the Administrator/Director of Patient Services, and the Clinical Managers were interviewed and did not provide an explanation for the findings. Patient #2 has a Start of Care date of 03/30/2024 with diagnosis Heart Failure documented in the Hospice Plan of Care dated 03/30/2024 to 06/027/2024. The Hospice Plan of Care for benefit period 03/30/2024 to 06/27/2024 documents the following orders for hospice aide/home health aide visit frequency: “;3 x week (three visits a week) for 13 weeks starting 04/02/2024 (week 2): State Date: 04/02/024, End Date: 06/27/2024.” The initial Medical Social Services Assessment dated 04/02/2024 documents: “;Education on the risks of aspiration;” “;Oxygen Concentrator is available in the event patient experience SOB (shortness of breath).” The Nursing Comprehensive Reassessment dated 04/01/2024 documents: patient use Oxygen 2L(liters)/min (minute) via nasal cannula as needed for shortness of breath. The Hospice Aide Assignment dated and signed by Registered Nurse on 03/30/2024, and reviewed Patient Clinical Manager on 04/01/2024, lacks documented oxygen safety and swallowing precautions. There is no documented evidence of the Registered Nurse preparing a complete written patient care instructions for the aide. On 05/22/2024 at 2:00 pm, the Administrator/Program Director and the Patient Clinical Managers were interviewed and did not provide an explanation for the finding.”

“Based on clinical record review and staff interview the hospice failed to ensure aide services are being provided as ordered in the aides plan of care. This was evident for one (1) of nineteen(19) clinical records reviewed (Patient #14). Failure to ensure aide services are provided as ordered in the aides plan of care, has the potential for negative patient outcomes. The findings are: 1. Patient #14 has a Start of Care date of 04/02/2023 with the following diagnoses “Senile Degeneration of Brain, Type 2 Diabetes Mellitus” documented in the Hospice Plan of Care dated 04/04/2024. The Hospice Plan of Care dated 04/04/2024 documents: “;HHA (home health aide): 5 x (times) week for 14 weeks starting 04/03/2024.” The Hospice Aide Assignment dated 04/04/2024 documents: Pain Rating daily. The Hospice Aide Visit Note lacks documented evidence of the pain rating daily. There is no documented evidence of the aide providing services that are included in the plan of care. On 05/23/2023 at 02:35pm, the Administrator/Director of Patient Services, and the Clinical Managers were interviewed and did not provide an explanation for the findings.”

“Based on clinical record review and staff interview the hospice registered nurse failed to ensure the supervision of the hospice aide no less frequently than every 14 days. This was evident for one (1) of nineteen (19) clinical records reviewed (Patient #4). Failure to ensure the supervision of the hospice aide no less frequently than every 14 days has the potential for negative patient outcomes. The findings are: 1. Patient #4 has a Start of Care date of 03/07/2024 with diagnoses Unspecified Protein Calorie Malnutrition, Pressure Ulcer of Other Site Stage 4, Paraplegia Unspecified documented in the Hospice Plan of Care for benefit period 03/07/2024 to 06/04/2024. The Hospice Plan of Care for benefit period 03/07/2024 to 06/04/2024 documents the following orders for hospice aide/home health aide visits/services: “;5 x week (five visits a week) for 14 weeks Starting 03/11/2024 (week 2).” The Hospice Aide Visit Notes document aide services were being provided five days a week (Monday to Friday) starting 03/11/2024 (week s). The Nursing Comprehensive Reassessment dated 04/12/2024 documents the first hospice aide supervision. There is no documented evidence of hospice aide supervision from 03/11/2024 to 04/11/2024. There is no documented evidence of the Registered Nurse supervising the hospice aide at least every 14 days to assess the quality of care and services provided. On 05/23/2024 at 2:30 pm, the Administrator/Program Director and the Patient Clinical Managers were interviewed and did not provide an explanation for the finding”

“Based on clinical record review and staff interview the Hospice failed to ensure that hospice care with skilled nursing facility must be provided in accordance with the hospice plan of care. This was evident for one (1) of nineteen(19) clinical records reviewed (Patient #11). Failure to ensure that hospice care with skilled nursing facility must be provided in accordance with the hospice plan of care has the potential for negative patient outcomes. The findings are: 1. Patient #11 has a Start of Care date of 10/13/2023 with the following diagnoses “Senile Degeneration of Brain, Hemiplegia following Cerebral Infraction” documented in the IDG Meeting Review/ Plan of Care dated 04/10/2024, certification period 04/10/2024 to 06/08/2024. The IDG Meeting Review/ Plan of Care dated 04/10/2024, 04/24/2024, and 05/08/2024 documents: PT (patient) resides in SNF (skilled nursing facility); DTI (deep tissue injury) R (right) heel Cleanse with: wound cleanser; Cover with: DPD (dry protective dressing). The Resident Treatment Administration Record from the skilled nursing facility documents treatment to right heel pressure ulcer on:04/01/2024 to 04/09/2024 Skin Prep Wipes,4/10/2024 to 4/30/2024 Dakins solution for cleaning wound then apply Santyl topical ointment,05/01/2024 to 05/06/2024 Santyl topical ointment,05/07/2024 to 05/13/2024 Skin Prep Pads. There is no documented evidence that the hospice care provided by the skilled nursing facility is in accordance with the hospice plan of care – treatment with wound cleanser in the hospice plan of care. On 05/23/2023 at 02:35pm, the Administrator/Director of Patient Services, and the Clinical Managers were interviewed and did not provide an explanation for the findings.”

“Based on clinical record review and staff interview the Hospice failed to ensure coordination of the hospice care with the skilled nursing facility. This was evident for three (3) of nineteen (19) clinical records reviewed (Patient’s #4, #5, and #11). Failure to ensure coordination of the hospice care with the skilled nursing facility has the potential for negative patient outcomes. The findings are: Patient #11 has a Start of Care date of 10/13/2023 with the following diagnoses “Senile Degeneration of Brain, Hemiplegia following Cerebral Infraction” documented in the IDG Meeting Review/ Plan of Care dated 04/10/2024, certification period 04/10/2024 to 06/08/2024. The Progress Notes from skilled nursing facility documents assessment with Right Heel pressure ulcer on:04/22/2024 and 04/29/2024 Wound Bed: 95%adherent eschar, 5% yellow slough05/06/2024 Wound Bed: dry adherent eschar05/13/2024 Wound Bed: 95 % eschar, 5% yellow slough. The Nursing Comprehensive Reassessment documents: Wound #1, Location: Right heel, Type: Other: DTI (deep tissue injury) on:04/26/2024 Wound Bed Tissue: Bloody05/02/2024 Wound Tissue: (blank)05/09/2024 Wound Bed Tissue: Bloody. There is no documented evidence of the coordination of the of the wound assessment - hospice assessment: no eschar or slough; and with the Skilled Nursing Facility assessment: with eschar and slough. On 05/23/2023 at 02:35pm, the Administrator/Director of Patient Services, and the Clinical Managers were interviewed and did not provide an explanation for the findings. Patient #4 has a Start of Care date of 03/07/2024 with diagnoses Unspecified Protein Calorie Malnutrition, Pressure Ulcer of Other Site Stage 4, Paraplegia Unspecified documented in the Hospice Plan of Care for benefit period 03/07/2024 to 06/04/2024. The Hospice Nursing Initial Comprehensive Assessment Admission Assessment dated 03/07/2024 documents the patient has the following six pressure ulcers: Wound #1 Sacrum Stage 4, Wound #2 Right Lateral Ankle Stage 4, Wound #3 Left Plantar Unstageable, Wound #4, Right Plantar unstageable, Wound #5 Left Lateral Heel Stage 4, and Wound #6 Left Ischial Stage 4. The Hospice Plan of Care for benefit period 03/07/2024 to 06/04/2024 documents: Skilled Nurse visit frequency one visit a week for 14 weeks; Integumentary: “;Multiple pressure ulcers mostly stage 4 and unstageable. Ongoing treatment to wounds. Integumentary Interventions: Assess skin integrity; Sacrum/left lateral heel, left lateral wounds cleanse with Dankins solution, apply collagen and cover with silver alginate. Cleanse left lateral plantar, left ankles, and right plantar wound with Dankins solution, then apply wet to moist betadine solution dressing; Responsible for wound care: Facility, Nurse to coordinate care with Hospice Nurse, Wound Care frequency Daily. The Registered Nurse/Skilled Nurse weekly visit notes dated 03/11/2024, 03/18/2024, 03/25/2024, 04/01/2024, 04/12/2024, 04/19/2024, 04/26/2024, 04/29/2024, 05/06/2024, 05/13/2013 lacks documented evidence of Hospice nurse coordination with the Facility regarding status/progress of Wound #5 and Wound #6 since the start of care. The clinical record lacked documented evidence the Registered Nurse coordinated the patient’s hospice care; relating to the patient’s wounds as specified in the plan of care. On 05/23/2024 at 2:30 pm, the Administrator/Program Director and the Patient Clinical Managers were interviewed and did not provide an explanation for the finding. Patient #5 has a Start of Care date of 03/09/2024, Discharge Date of 04/27/2024, with diagnoses Chronic Obstructive Pulmonary Disease, Anxiety Disorder, Major Depression, Respiratory Failure Unspecified with Hypoxia, documented in the Hospice Plan of Care for benefit period 03/09/2024 to 06/06/2024. The Physician Order dated 04/29/2024 documents: “;Patient discharged from hospice; admitted to (hospital) on 04/27/24;” Verbal Order - Effective Date 04/27/2024. The clinical record lacked documented evidence the Registered Nurse coordinating the Skilled Nursing Facility regarding the reason for the patients hospitalization. On 05/24/2024 at 1:15 pm, the Administrator/Program Director and the Patient Clinical Managers were interviewed. The Patient Clinical Manager stated that the Hospice has “;no record” of the Facility calling the 24/7 on call number, and there is “;no record” of the communication of who informed the Hospice of the patients hospitalization.”