Hospice of the Sacred Heart

“Based on documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler system in three instances, affecting one of one floor. Findings include: 1. Observation on January 30, 2025, at 12:23 p.m., revealed the facility lacked current internal valve and internal pipe inspection data, as well as current sprinkler gauge data (service on internal pipe, internal valve, and sprinkler gauge replacement last performed on 5/3/2018). Exit interview with the Facility Administrator on January 30, 2025, between 1:00 p.m., and 1:10 p.m., confirmed the automatic sprinkler system deficiencies.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by document review, interview, and personnel record review. In 4 of 10 (40%) personnel records of staff providing direct patient care revealed the agency did not ensure that competency assessments were conducted per the agency’s policy. POLICY AND PROCEDURES: The agency’s Competency Assessment policy (policy number HR.C10; approved 01/23/2019) stated, in part, that “performance evaluations are specific to the skills needed for each job category” and “performance evaluations are completed annually and as needed”. PERSONNEL RECORD 4: A review of the personnel record for this licensed practical nurse who was hired on 05/30/2018 revealed a performance evaluation/competency assessment dated 12/02/2024. The previous performance evaluation/competency assessment was dated 12/16/2021. There was no documented evidence of performance evaluations/competency assessments completed in the 4th quarter 2023 ending on 12/31/2023 after the end of the Public Health Emergency (PHE). PERSONNEL RECORD 7: A review of the personnel record for this licensed practical nurse who was hired on 06/28/2010 revealed a performance evaluation/competency assessment dated 06/05/2024. The previous performance evaluation/competency assessment was dated 03/26/2021. There was no documented evidence of performance evaluations/competency assessments completed in the 4th quarter 2023 ending on 12/31/2023 after the end of the Public Health Emergency (PHE). PERSONNEL RECORD 8: A review of the personnel record for this registered nurse who was hired on 06/07/2016 revealed a performance evaluation/competency assessment dated 06/07/2024. The previous performance evaluation/competency assessment was dated 06/07/2021. There was no documented evidence of performance evaluations/competency assessments completed in the 4th quarter 2023 ending on 12/31/2023 after the end of the Public Health Emergency (PHE). PERSONNEL RECORD 11: A review of the personnel record for this clinical director who was hired on 12/19/2014 revealed a performance evaluation/competency assessment dated 04/15/2021. There was no documented evidence of performance evaluations/competency assessments completed in the 4th quarter 2023 ending on 12/31/2023 after the end of the Public Health Emergency (PHE) or for 2024. In an interview on 01/30/2025 with the Director of Human Services (Personnel Record 17) stated that the competency assessment process is combined with and part of the annual performance evaluation process. She also stated that if the annual performance evaluation was not completed for a staff member, then the competency assessment would not have been completed as well.”

“It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) live discharge clinical records reviewed revealed that the agency did not ensure that the hospice discharge summary was forwarded to the receiving facility. CLINICAL RECORD 20: The patient elected the hospice benefit on 10/21/2023 with a diagnosis of Malignant neoplasm of the rectum. The patient was transferred to Medicare/Medicaid facility on 06/28/2024. During joint review of the clinical record and interview with the director of quality assurance there was no documented evidence found that ensured the agency forwarded a discharge summary or called report to the receiving facility.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) live discharged clinical records reviewed revealed that the agency did not ensure that the discharge summary was completed with the required information. CLINICAL RECORD 20: The patient elected the hospice benefit on 10/21/2023 with a diagnosis of malignant neoplasm of the rectum. The patient was transferred to a hospice facility outside of the service area. During joint review and interview with the director of quality assurance the was no documented evidence that the RN completed a discharge summary with all required information.”

“It is required that the hospice inpatient facility provides meals to each patient that are palatable, attractive, and served at the proper temperature. This standard was not met as evidenced by document review, interview and observation. A tour of the inpatient unit on 01/29/2025 revealed that the agency did not ensure that meals provided to patients were served at the proper temperature as the monitoring of temperature checks were not maintained per agency policy, POLICY AND PROCEDURE DOCUMENT: The agency’s Food Temperature and Tray Audit Protocol stated, in part, that “food temperature will be taken on food items being served to the patient” and “following information will be documented on the attached audit tool.” A review of the audit tool revealed that the temperature of the food provided was to be recorded for each meal served to each patient. IPU OBSERVATION: During a tour of the inpatient unit on 01/29/2025, only partially completed logs for the tracking of meals served to patients were able to be produced. In addition, there was no documented evidence of the food temperature logs for most of 2022, 2023, and 2024. During an interview on 01/29/2025 with the Clinical Director of the inpatient unit (Personnel Record 11), stated that the temperature checks on meals served to patients was inconsistent and incomplete. He also stated that no logs were completed for much of 2022, 2023, and 2024. A tour of the inpatient unit on 01/29/2025 revealed that the agency did not ensure that meals provided to patients were served at the proper temperature as monitoring of temperature checks was not maintained to agency policy,”

“It is required that the hospice inpatient facility provides meals to each patient that are obtained, stored, prepared, distributed, and served under sanitary conditions. This standard was not met as evidenced by document review, interview and observation. A tour of the inpatient unit on 01/29/2025 revealed that the agency did not ensure that meals provided to patients were served under sanitary conditions as dishes and utensils used in the serving of patient meals were not sanitized. REGULATION: The CMS regulation 483.60(i)(2) (F812) pertaining to the manual washing and sanitizing of dishes and utensils in a healthcare facility kitchen stated, in part, that “A 3-step process is used to manually wash, rinse, and sanitize dishware correctly. The first step is thorough washing using hot water and detergent after food particles have been scraped off. The second is rinsing with hot water to remove all soap residues. The third step is sanitizing with either hot water or a chemical solution” and “After washing and rinsing, dishes and utensils are sanitized by immersion in either hot water (at least 171 degrees F) for 30 seconds or a chemical sanitizing solution used according to manufacturer’s instructions.” IPU OBSERVATION: During a tour of the inpatient unit on 01/29/2025, dishes and utensils used in the serving of patient meals, including a bowl and a fork, were observed to be drying in a dish rack after being washed by hand. The dishwasher in the food preparation area which was also used to clean dishes and utensils used to serve food to patients was a domestic model dishwasher. During an interview on 01/29/2025 with the Clinical Director at the inpatient unit (Personnel Record 11) and the Director of Quality Assurance and Risk Management, they stated the agency did not have a policy specific to the washing of dishes in the inpatient unit. The Clinical Director of the inpatient unit also stated that dishes and utensils used in the serving of meals to patients were sometimes washed by hand and sometimes washed in the dishwasher. He also stated that the hand washing process involved scraping the dishes, washing them in hot and soapy water, rinsing them in hot water, and air drying them. He also stated that the facility was served by a single hot water heater. He also stated that the temperature of the dishwasher was not monitored. A tour of the inpatient unit on 01/29/2025 revealed that the agency did not ensure that meals provided to patients were served under sanitary conditions as dishes and utensils used in the serving of patient meals were not sanitized.”

“It is required that the hospice inpatient facility documents the training and demonstration of competency in restraint or seclusion in each designated employee’s personnel record. This standard was not met as evidenced by document review, interview and personnel record review. In 17 of 17 (100%) of personnel records reviewed, the agency did not ensure that training in restraint and seclusion was provided to all staff as per agency policy. POLICY AND PROCEDURE DOCUMENT: The agency’s Restraint/Seclusion Free Environment policy (policy number PC.R11; approved on 10/18/2019) stated, in part, that “All staff receive training upon orientation and annually thereafter on the hospice’s philosophy of a restraint/seclusion free environment.”. The policy further states that “staff is trained on the use of nonphysical and nonchemical intervention skills”. PERSONNEL RECORD 1: There was no documented evidence that indicated that annual training on the hospice’s philosophy of a restraint/seclusion free environment was provided to this social worker who was hired on 11/22/2010. PERSONNEL RECORD 2: There was no documented evidence that indicated that annual training on the hospice’s philosophy of a restraint/seclusion free environment was provided to this social worker who was hired on 11/09/2020. PERSONNEL RECORD 3: There was no documented evidence that indicated that annual training on the hospice’s philosophy of a restraint/seclusion free environment was provided to this chaplain who was hired on 11/30/2015. PERSONNEL RECORD 4: There was no documented evidence that indicated that annual training on the hospice’s philosophy of a restraint/seclusion free environment was provided to this licensed practical nurse who was hired on 05/30/2018. PERSONNEL RECORD 5: There was no documented evidence that indicated that training upon orientation or annual training on the hospice’s philosophy of a restraint/seclusion free environment was provided to this registered nurse who was hired on 03/06/2023. PERSONNEL RECORD 6: There was no documented evidence that indicated that training upon orientation or annual training on the hospice’s philosophy of a restraint/seclusion free environment was provided to this registered nurse who was hired on 06/21/2023. PERSONNEL RECORD 7: There was no documented evidence that indicated that annual training on the hospice’s philosophy of a restraint/seclusion free environment was provided to this licensed practical nurse who was hired on 06/28/2010 and who works in the agency’s inpatient unit. PERSONNEL RECORD 8: There was no documented evidence that indicated that annual training on the hospice’s philosophy of a restraint/seclusion free environment was provided to this registered nurse who was hired on 06/07/2016 and who works in the agency’s inpatient unit. PERSONNEL RECORD 9: There was no documented evidence that indicated that annual training on the hospice’s philosophy of a restraint/seclusion free environment was provided to this medical director who was contracted on 07/01/2019 and who works in the agency’s inpatient unit. PERSONNEL RECORD 10: There was no documented evidence that indicated that annual training on the hospice’s philosophy of a restraint/seclusion free environment was provided to this chief executive officer who was hired on 07/01/2019. PERSONNEL RECORD 11: There was no documented evidence that indicated that annual training on the hospice’s philosophy of a restraint/seclusion free environment was provided to this clinical director who was hired on 12/19/2014 and who works in the agency’s inpatient unit. PERSONNEL RECORD 12: There was no documented evidence that indicated that annual training on the hospice’s philosophy of a restraint/seclusion free environment was provided to this chief operating officer who was hired on 05/15/2004. PERSONNEL RECORD 13: There was no documented evidence that indicated that annual training on the hospice’s philosophy of a restraint/seclusion free environment was provided to this director of patient services who was hired on 04/09/2007. PERSONNEL RECORD 14: There was no documented evidence that indicated that annual training on the hospice’s philosophy of a restraint/seclusion free environment was provided to this volunteer coordinator who was hired on 02/20/2007. PERSONNEL RECORD 15: There was no documented evidence that indicated that annual training on the hospice’s philosophy of a restraint/seclusion free environment was provided to this bereavement coordinator who was hired on 03/10/2006. PERSONNEL RECORD 16: There was no documented evidence that indicated that training at orientation and annual training on the hospice’s philosophy of a restraint/seclusion free environment was provided to this volunteer who was signed on 05/16/2023. PERSONNEL RECORD 17: There was no documented evidence that indicated that annual training on the hospice’s philosophy of a restraint/seclusion free environment was provided to this director of human services who was hired on 03/01/2004. In an interview on 01/30/2025 with the Director of Human Services (Personnel Record 17), she stated that the agency had not been providing training to staff in the area of being a restraint/seclusion free environment as is stated in agency policy. She also stated that this policy would apply to all staff of the agency, not only to the staff of the inpatient unit.”

“Based on review of hospice policy/procedure and clinical records and based on interview with the Director of Human Services (Employee #7), the hospice failed to ensure visit frequencies were established in accordance with hospice admission orders for three (3) of fourteen (14) active patients for whom the initial certification period was reviewed. (Patients #14, #20 and #21) Findings include: On January 10, 2025 at approximately 3:12 PM, review of hospice policy HC.V05, titled “Visit Frequencies” revealed the following under “Procedure”: 2. Visit frequency or routine orders must be individualized to address the specific patient’s needs... Patient #14: On January 9, 2025 at approximately 12:34 PM, review of the clinical record revealed the hospice services were initiated on 12/30/2024 as documented on the hospice election of benefit form dated 12/30/2024. Review of the “Physican Orders for Hospice Patient” dated 12/30/2024 revealed the hospice admission orders included the following physician orders: RN to assess patient and establish plan of care with pt/family/caregiver and attending physician. Establish frequencies within 5 days of patient admission. Review of “Nurse Progress Note Initial Assessment” documentation for the 12/30/2024 start of care (admission) visit revealed that in addition to skilled nursing (SN) services, the patient accepted social work (SW) services. Review of routine visit documentation revealed SN services were provided on 12/30/2024 and 01/02 and 01/07/2025 and that SW services were provided on 01/03/2025. There was no documentation in the clinical record which provided evidence that a SN and SW visit frequency had been established within 5 days of the patient admission. Patient #20: On January 9, 2025 at approximately 3:30 PM, review of the clinical record revealed the hospice services were initiated on 12/20/2024 as documented on the hospice election of benefit form dated 12/20/2024. Review of the “Physican Orders for Hospice Patient” dated 12/20/2024 revealed the hospice admission orders included the following physician orders: RN to assess patient and establish plan of care with pt/family/caregiver and attending physician. Establish frequencies within 5 days of patient admission. Review of “Nurse Progress Note Initial Assessment” documentation for the 12/20/2024 start of care (SOC) visit revealed that in addition to SN services, the patient accepted SW and hospice aide services. Review of routine visit documentation SN services were provided on 12/20, 12/23 and 12/30/2024 and on 01/02 and 01/06/2025, that SW services were provided on 12/23 and 12/31/2024 and that hospice aide services were provided on 12/31/2024 and 01/02 and 01/06/2025. Review of “Physician Order for Hospice Patient” documentation revealed physician orders for SN, SW and hospice aide visit frequencies were obtained on 12/31/2024 which was more than 5 days after the SOC. There was no documentation in the clinical record which provided evidence that SN, SW and hospice aide visit frequencies had been established within five (5) days of the patient admission. Patient #21: On January 9, 2025 at approximately 3:49 PM, review of the clinical record revealed the hospice services were initiated on 12/31/2024 as documented on the hospice election of benefit form dated 12/31/2024. Review of the “Physican Orders for Hospice Patient” dated 12/31/2024 revealed the hospice admission orders included the following physician orders: RN to assess patient and establish plan of care with pt/family/caregiver and attending physician. Establish frequencies within 5 days of patient admission. Review of “Nurse Progress Note Initial Assessment” documentation for the 12/31/2024 SOC visit revealed that in addition to SN services, the patient accepted SW and hospice aide services. Review of routine visit documentation SN services were provided on 12/31/2024 and on 01/02/2025 and that SW services were provided on 01/02/2025. There was no documentation in the printed clinical record which provided evidence hospice aide services had been provided between 12/31/2024 and 01/08/2025. Review of “Physician Order for Hospice Patient” documentation revealed physician orders for SN, SW and hospice aide visit frequencies were obtained on 01/06/2025 which was more than 5 days after the SOC. There was no documentation in the clinical record which provided evidence that SN, SW and hospice aide visit frequencies had been established within five (5) days of the patient admission. During interview conducted on January 10, 2025 at approximately 3:35 PM, the Director of Human Services confirmed there was no documentation in the clinical record which provided evidence that the above referenced frequencies had been established within five (5) days of patient admission for the above identified patients.”

“Based on review of hospice policies/procedures, initial tuberculosis (TB) screening guidance from the Centers for Disease Control (CDC) and personnel files and based on interview with the Director of Human Services (Employee #7), the hospice failed to ensure TB screening was conducted in accordance with hospice policies/procedures and CDC recommendations for two (2) of two (2) core hospice employees whose date of hire was after January 13, 2022. (Employees 4 and #6) Findings include: On January 10, 2025 at approximately 2:54 PM, review of hospice policy HR.H10, titled “Health/Physical Requirements” revealed the following under “Procedure”: 6. All employees and volunteers are required to have documented evidence of a tuberculin screening prior to patient contact. All employees and volunteers are required to complete the two-step PPD (tuberculin purified protein derivative) test if it has been more than one year since their last test was given. The second test must be performed within one to three weeks of the first test. On January 10, 2025 at approximately 3:20 PM, review of hospice policy PC.I60, titled “Infection Control-Tuberculosis Exposure Plan”, revealed the following under “Procedure”: 1. Testing...(C) Information from the baseline individual TB risk assessment should be used to interpret the results of a TB blood test or TB skin test given on hire. On January 10, 2025 at approximately 3:31 PM, review of CDC recommendations for initial TB screening for health care personnel revealed the following as documented on the CDC website: https://www.cdc.gov/tb-healthcare-settings/hcp/screening-testing/baseline-testing.html : The TB screening process for health care personnel includes: -A baseline individual TB risk assessment; -TB symptom evaluation; and -A TB test (TB blood test or a TB skin test (2-Step)). On January 10, 2025 at approximately 10:45 AM and January 14, 2025 at approximately 8:09 AM, review of personnel file documentation revealed the following: Employee #4: The date of hire of the registered nurse (RN) was 06/21/2023. Review of TB questionnaire documentation dated 06/21/2023 revealed the RN experienced an allergic reaction to a prior TB skin test and that the RN did not have a past history of a positive PPD result. There was no documentation in the personnel file which provided evidence that a TB blood test had been completed. Employee #6: The date of hire of the RN was 03/06/2023. There was no documentation in the personnel file which provided evidence the RN had completed the second step of the TST. During interview conducted on January 10, 2025 at approximately 3:35 PM, the Director of Human Services confirmed TB screening was not conducted in accordance with the above referenced policies/procedures, nor CDC recommendations, for the above identified core hospice staff members.”

“Based on review of hospice policy/procedure and clinical records, pressure injury (bedsore) guidance from the Cleveland Clinic and the Hospice and Palliative Nurses Association, and based on interview with the Director of Human Services (Employee #7), the hospice failed to ensure pressure-type wound assessment was completed in accordance with hospice policy/procedure and professional standards for three (3) of three (3) patients for whom an open wound was assessed by skilled nursing (SN) staff. (Patients #5, #11 and #25) Findings include: On January 10, 2025 at approximately 3:15 PM, review of hospice policy PC.A80, titled “Comprehensive Assessment of the Patient” revealed the following under “Procedure”: 6. The hospice’s assessment and reassessment tool contain data elements that allow for the measurement of outcomes. On January 10, 2025 at approximately 3:13 PM, review of the hospice procedure titled “Protocol for Wound Care” revealed the following: 1. Assessment...A. Once a wound has been identified and staged, the following categories will be part of the ongoing assessment: Size... On January 14, 2025 at approximately 9:00 AM, review of the Cleveland Clinic website revealed the following under the article titled “Bedsores (Pressure Injuries)” https://my.clevelandclinic.org/health/diseases/17823-bedsores-pressure-injuries : Stages of bedsores or pressure ulcers include....Stage 2: A shallow wound with a pink or red base develops. You may see skin loss, abrasions and blisters. On January 14, 2025 at approximately 9:30 AM, review of the Hospice and Palliative Nurses Association article titled “Hospice & Palliative Wound Care” revealed the following: Wound Assessment...perform a wound assessment on admission, weekly, and if the patients condition deteriorates. Key clinical observations include...Size (length, width, and depth)... Patient #5: On January 7, 2025 at approximately 11:01 AM, review of the clinical record revealed hospice problems include skin integrity and that the problem interventions include assessment and monitoring for skin integrity changes as documented on the “Combined Disciplinary Plan of Care” dated 01/02/2025. Review of “Inpatient Nurse Progress Note Routine Visit” documentation dated 01/05/2025 revealed a new open wound was present on the left inner buttocks and that barrier cream was applied to the wound. There was no documentation in the clinical record which provided evidence the inpatient unit SN (Employee #12) assessed the depth of the open left inner buttocks wound on 01/05/2025. Patient #11 (Closed Record): On January 9, 2025 at approximately 9:20 AM, review of the clinical record revealed a new open pressure area was present on the left inner ankle, that a new wound treatment was ordered and that skin integrity interventions included assessment and monitoring wound for changes in healing as documented on the “Nurse Progress Note Routine Visit” dated 08/07/2024. There was no documentation in the clinical record which provided evidence the hospice SN (Employee #13) assessed the depth of the open left ankle wound on 08/07/2024. Patient #25: On January 10, 2025 at approximately 7:39 AM, review of the clinical record revealed a new open pressure blister was present on the right buttock and that goals included for skin integrity to be maintained as feasible as documented on the “Nurse Progress Note Routine Visit” dated 01/06/2025. There was no documentation in the clinical record which provided evidence the hospice SN (Employee #14) assessed the depth of the open right buttock wound on 01/06/2025. During interview conducted on January 10, 2025 at approximately 3:35 PM, the Director of Human Services confirmed there was no documentation in the clinical record which provided evidence the depth of the above referenced wounds had been assessed for the above identified patients.”

“Based on review of hospice policy/procedure and documentation and based on interview with the Director of Human Services (Employee #7), the hospice failed to ensure one (1) of two (2) durable medical equipment (DME) companies were accredited as a DME supplier. (DME #1) Findings include: On January 10, 2025 at approximately 2:48 PM, review of hospice policy PC.D30, titled “Durable Medical Equpment” revealed the following under “Procedures”: 1. The hospice maintains contracts with accredited DME providers for the provision of safe and effective DME for the hospice patients. During interview conducted on January 8, 2025 at approximately 4:02 PM, the Director of Human Services reported DME supplier #1 (DME #1) supplies Broda chairs (tilt-in-space positioning chairs) to hospice patients. On January 8, 2025 at approximately 3:12 PM, review of hospice contract documentation revealed DME #1 became a hospice contracted DME supplier effective 05/29/2024. There was no documentation which provided evidence that DME #1 had obtained accreditation as a DME supplier. On January 10, 2025 at approximately 2:59 PM, review of hospice documentation revealed DME #1 supplied 11 hospice patients with DME equipment between May and December 2024. During interview conducted on January 10, 2025 at approximately 3:35 PM, the Director of Human Services confirmed there was no documentation which provided evidence that DME #1 had obtained accreditation as a DME supplier.”

“Based on review of hospice policy/procedure, documentation and clinical records, and based on interview with skilled nursing facility staff (SNF-social worker (SW)) and the hospice Director of Human Services (Employee #7), the hospice failed to provide a SNF with a copy of the current hospice plan of care for two (2) of two (2) patients. (Patients #6 and #7) Findings include: On January 10. 2-25 at approximately 2:50 PM, review of hospice policy PC.H40, titled Hospice Care for Nursing Facility Residents-Coordination of Care” revealed the following under “Procedures”: 3. The following information is provided to the facility: (1) The most recent hospice plan of care specific to each patient... On January 8, 2025 at approximately 2:44 PM, review of the hospice contract with SNF #1, which was signed by hospice administrative designee and SNF administrator on 12/13/2021, revealed the following under “Section IV-Cooperation in Professional Management”: The Home (SNF) will designate a member of the Home’s Interdisciplinary Team to be responsible for working with Hospice representatives to coordinate care by the Home and Hospice staff to the patients. The individual must be responsible for...(4) Obtaining pertinent information from the Hospice including the most recent hospice plan of care specific to each patient... Patient #6: During home visit conducted at SNF #1 on January 8, 2025 at approximately 8:40 AM, review of the SNF hospice folder revealed a hospice form titled “Nursing Facility Plan of Care” was maintained at the SNF which included visit frequencies for skilled nursing (SN), hospice aide (personal care visits-PCV) and the social worker (SW). The “Nursing Facility Plan of Care” form failed to include the hospice diagnosis, a list of hospice problems and affiliated hospice interventions and goals, nor did the form include a list of current medications. On January 9, 2025 at approximately 7:15 AM, review of the hospice clinical record revealed the following was documented on the hospice Combined Disciplinary Plan of Care dated 11/17/2024: -The start of care was 05/15/2024 and the terminal diagnosis is senile degeneration of the brain: -Hospice problems and affiliated interventions and goals include “Neuro/Mental/Emotional-Issues”: and -Current medications include Seroquel (medication used to treat bipolar disorder) and Percocet (pain medication). There was no documentation in the hospice SNF folder nor in the hospice clinical record which provided evidence that a copy of the hospice “Combined Disciplinary Plan of Care” for the recertification period of 11/11/2024 through 01/09/2025 had been provided to the SNF. Patient #7: During home visit conducted at SNF #1 on January 8, 2025 at approximately 9:15 AM, review of the SNF hospice folder revealed a hospice form titled “Nursing Facility Plan of Care” was maintained at the SNF which included visit frequencies for SN, PCV, SW and spiritual counseling. The “Nursing Facility Plan of Care” form failed to include the hospice diagnosis, a list of hospice problems and affiliated hospice interventions and goals, nor did the form include a list of current medications. On January 9, 2025 at approximately 7:55 AM, review of the hospice clinical record revealed the following was documented on the hospice Combined Disciplinary Plan of Care dated 12/31/2024: -The start of care was 09/08/2023 and the terminal diagnosis is other frontotemporal neurocognitive disorder (form of dementia), -Hospice problems and affiliated interventions and goals included “Neuro/Mental/Emotional-Issues”: and -Current medications include morphine sulfate. There was no documentation in the hospice SNF folder nor in the hospice clinical record which provided evidence that a copy of the hospice “Combined Disciplinary Plan of Care” for the recertification period of 12/31/2024 through 02/28/2025 had been provided to the SNF. During interview conducted on 01/08/2025 at approximately 9:50 AM, the SNF-SW reported SNF #1 does not require that a copy of the hospice plan of care be provided to the SNF. The SNF-SW confirmed there was no evidence that a copy of the current hospice plan of care (“Combined Disciplinary Plan of Care”) had been provided to the SNF. During interview conducted on January 10, 2025 at approximately 3:35 PM, the hospice Director of Human Services confirmed there was no documentation which provided evidence that a copy of the current “Combined Disciplinary Plan of Care” had been provided to SNF #1 for the above referenced patients.”