Suncrest Hospice

“Based on policy review, medical record review and interview, the facility failed to ensure nurses documented wound measurements per facility policy for 1 of 3 (Patient #5) sampled patients with wounds and failed to develop and implement a plan of care for Hospice Aide Services for 1 of 13 (Patient #7) sampled active hospice patients reviewed. The findings included: 1. Review of the facility’s “WOUND ASSESSMENT, DOCUMENTATION AND PHOTOGRAPHY” policy revised 3/1/2021, revealed, “…Wound measurements (weekly) including the length, depth, and width of the wound in centimeters…” Review of the facility’s “PLAN OF CARE” policy reviewed 10/1/2024, revealed, “...The plan of care must include all services necessary for the palliation and management of terminal illness…Detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs…Coordination of care...” Review of the facility’s “Physician Orders” policy revised 10/1/2024, revealed, “...Services are provided according to the most recent orders updating the patient’s plan of care…” 2. Medical record review for Patient #5 revealed a certification period of 4/9/2026 through 7/7/2026. Patient #5 was documented as having a wound to the sacral area at the beginning of the certification period. Review of “Wound Assessment Tool Report” Skilled Nurse (SN) notes beginning 4/13/2026 through 6/24/2026 revealed no weekly wound measurements were performed the weeks of 5/3/2026 and 5/10/2026. During an interview on 5/23/2026 at 10:10 AM, the Executive Director stated wound measurements were supposed to be done once a week and confirmed no wound measurements for Patient #5 were documented for the weeks of 5/3/2026 and 5/10/2026. 3. Medical record review for Patient #7 revealed a Start of Care (SOC) date of 2/11/2026 with diagnoses that included Dysphagia. Review of the Plan of Care (POC) for 5/12/2026 through 8/9/2026, revealed Home Hospice Aide (HHA) visit frequency of 2 times weekly for 13 weeks beginning 5/12/2026. Review of the Client Episode Coordination Notes revealed missed visits notifications were made by the HHA on 5/14/2026, 5/19/2026, 5/21/2026, 5/27/2026, 5/29/2026, 6/3/2026 and 6/5/2026. The reason for the missed visits was documented that the patient did not have a care plan in place. There was no documentation of why the HHA visits were missed the week of 5/3/2026, and there was no documentation the physician was notified of the missed visits. Patient #7 had no Aide Care Plan developed until 6/5/2026. During an interview on 6/23/2026 at 11:02 AM, the Executive Director stated the aide sent a message to the nurse, and she was out of town, and no care plan was completed until 6/5/2026 after a different nurse was notified.”

“Based on policy review, medical record review and interview, the facility failed to follow the Plan of Care (POC) for 2 of 13 (Patient #5 and #6) active patients reviewed. The findings included: 1. Review of the facility’s “PLAN OF CARE” policy reviewed 10/1/2024, revealed, “...The plan of care must include all services necessary for the palliation and management of terminal illness…Detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs…Coordination of care...” 2. Medical record review for Patient #5 revealed a Start of Care (SOC) date of 7/9/2026 with diagnoses that included Heart Failure. Review of the Plan of Care (POC) for 4/9/2026 through 7/7/2026 revealed a Hospice Aide (HHA) visit frequency of 1 time weekly for one week, then 2 times weekly for 12 weeks beginning on 4/9/2026. Record review revealed Patient #5 had no HHA visits documented the week of 5/3/2026. There was no documentation of why the HHA visits were missed the week of 5/3/2026, and there was no documentation the physician was notified of the missed visits. 3. Medical record review for Patient #6 revealed a Start of Care (SOC) date of 11/13/2025 with diagnoses that included Chronic Obstructive Pulmonary Disease. Review of the Plan of Care (POC) for 5/12/2026 through 7/10/2026 revealed HHA visit frequency of 3 times weekly for 9 weeks beginning on 5/12/2026. Record review revealed Patient #5 had 2 HHA visits documented the week of 5/17/2026. There was no documentation of why the HHA third visit was missed the week of 5/17/2026, and there was no documentation the physician was notified of the missed visit. 4. During an interview on 6/23/2026 at 10:15 AM, the Executive Director stated there was no documentation of a missed visit, or the physician being notified for the visits listed above for Patient #5 and #6..”