Providence Hospice

“It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure nursing care and services were provided per the patient plan of care. CLINICAL RECORD 4: The patient elected the hospice benefit on 09/13/2024 with a diagnosis of chronic obstructive pulmonary disease. The hospice plan of care dated 03/12/2025 to 05/10/2025 included an order for skilled nursing 1 x a week and 1-2 as needed visits for symptom management. Skilled nursing visits were documented on the following dates: 03/13/2025, 03/20/2025, 04/03/2025 (11 days), 04/10/2025, 04/17/2025, 04/24/2025, 05/01/2025, and 05/08/2025. The clinical record did not have documented evidence that the patient was seen the week of 03/23/2025 – 03/29/2025, and there was no evidence as to why the patient was not seen. During an interview with the Senior Director/Administrator/Supervising Nurse (Personnel Record 7) on 08/12/2026, she stated she does not know why the visit was missed at that time, but they will make sure and reeducate the clinical staff on documentation of missed visits.”

“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, and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record review of a patient that was discharged from hospice services due to admission to facility revealed the agency did not provide the facility with the discharge summary. CLINICAL RECORD 18: The patient elected the hospice benefit on 07/14/2025. The patient was transferred to another hospice on 04/23/2026. The clinical record did not contain documented evidence that the receiving facility was forwarded a copy of the hospice discharge summary. During an interview with the Senior Director/Administrator/Supervising Nurse (Personnel Record 7) on 08/12/2026, she stated that they reviewed the documentation and were unable to locate evidence that the information was sent to the receiving hospice.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical record review of patients who have been discharged from hospice services revealed that the agency did not ensure a copy of the discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 19: The patient elected the hospice benefit on 11/21/2025. The patient revoked the hospice benefit on 01/03/2026. The clinical record did not contain documented evidence that the agency forwarded a copy of the discharge summary to the patient’s attending physician. During an interview with the Senior Director/Administrator/Supervising Nurse (Personnel Record 7) on 08/12/2026, she stated that they reviewed the documentation and were unable to locate evidence that a copy of the discharge summary was sent to the attending physician.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current: Prescription and over-the-counter (OTC) drugs and supplements; Herbal remedies; and Other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: The effectiveness of drug therapy; Drug side effects; and Actual or potential drug interactions; and Duplicate drug therapy; Drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in hospice populations are anticipated, and as appropriate, preventive measures are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This is a Continued Required Action This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 7 (29%) Clinical records reviewed, the agency did not ensure that all medication profiles were updated accurately so that a full medication review for potential interactions was completed. #2-004 Medication Profile [revision 12/30/2022] stated in part: “A drug regimen review will be performed at the time of initial and comprehensive assessment when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication. The review will identify drug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy, duplicative drug therapy, and noncompliance with drug therapy.” Clinical Record 1: A skilled nurse (SN) prn (as needed assessment note dated 12/02/2023 revealed that the patient had increased respiratory secretions of many different colors and increased shortness of breath. The SN documented that the physician was called and ordered a Z Pak (antibiotic) and the pharmacy delivered this medication. There was no documented evidence that the medication profile was updated as of the record review on 12/19/2023. The interdisciplinary group meeting on 12/06/2023 stated that the patient started a z pack, but no review was documented of this new medication. Clinical Record 2: The initial comprehensive assessment was dated 12/05/2023. A coordination note dated 12/05/2023 that Nystatin (antifungal) was delivered to the patient for redness under the breasts. There was no documented evidence that the medication profile was updated as of the record review on 12/19/2023 and the medication was reviewed for potential interactions. During an interview with the Chief Compliance Officer on 12/20/2023 she stated that the orders for the medications were added for the two records and a drug review has now been completed.”

“It is required that each patient’s individualized written plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following: Drugs and treatment necessary to meet the needs of the patient. This is a Continued Required Action This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 7 (14%) Clinical Records reviewed the agency did not ensure that the plan of care documented all medications that the patient was taking as required by agency policy. #9-017 The plan of Care [reviewed date 12/30/2022] stated in part: “The written plan of care will contain, but will not be limited to, the following: Drugs and treatments.” Clinical Record 2: The nurse documented the initial comprehensive assessment on 12/05/2023 and a coordination note on 12/05/2023 that she delivered the nystatin powder to the family and provided instructions for its use. The medication was not documented on the initial plan of care. The interdisciplinary group (IDT) meeting documented on 12/06/2023 and signed by the physician did not document the Nystatin that the patient was using for redness under her red breasts. The next IDT was scheduled for 12/19/2023. During an interview with the Chief Compliance Officer on 12/20/2023, she stated that the medication had now been added to the medication profile which will flow to the updated plan of care.”

“It is required that a hospice that provides inpatient care directly in its own facility is responsible to ensure that staffing for all services reflects the level of intensity of services needed to ensure that the patient’s plan of care outcomes are achieved and negative outcomes avoided. This CONDITION was not met as evidence by observations, interviews, and document reviews with the Inpatient Manager and Facility Maintenance Director which revealed the agency failed to address real or potential threats to the health and safety of patients, hospice staff, visitors, others, and property [HSIC.8.1/L825]; failed to comply with the federal, state, and local health and safety codes [HSIC.14.I/L827]; failed to provide a sanitary environment by following current standards of practice, including nationally recognized infection control precautions and avoiding sources and transmission of infections and communicable diseases [HSIC.25.I/L834]; failed to ensure the available clean linen was stored in a manner to prevent the spread of infection [HSIC.26.I/L835]; and failed to ensure that food was served to patients at the proper temperature [HSIC.28.I/L838]. The cumulative effect of this issue has resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment to avoid negative outcomes for the condition of participation CFR 418.110: Hospices that provide Inpatient Care Directly. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment.”

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. (L This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 26 (4%) In the clinical records that were reviewed, the agency did not ensure the hospice Interdisciplinary group completed an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. Document 4: No 1-104 Comprehensive Assessment [revision date December 30, 2022], stated in part, “A comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with the attending physician and will include: The patients psychosocial status, including emotional barriers to treatment, cognitive limitations, memory and orientation, family relationships, social history, source and adequacy of environmental and other resources, coping mechanisms, and the patients and family/caregivers reaction to the illness.” Clinical Record 11: The hospice benefit of the election was signed on 03/07/2023 with an initial plan of care documented on 03/07/2023 for social work to evaluate. The MSW (social worker) documented that a call was made on 03/07/2023 and left a vm (voice mail), There was no further documentation until 03/20/2023 when the social worker made an initial visit. The nurse visited twice the first week and the home health aide visited five times a week, and opportunity for the social worker to visit should have noted if the family wanted or did not want the social worker to evaluate the patient. The assessment was 8 days late. There was no documentation prior to 03/20/2023 that the RN completed the psychosocial needs that included the emotional barriers to treatment, cognitive limitations, family relationships, social history, source and adequacy of environmental and other resources for the patient. The initial comprehensive assessment did not document the psychosocial needs. During an interview on 3/20/2023, the Administrator and Quality Manager confirmed that the documentation did not support why the social work visit was not made prior to 03/20/2023, and the social assessment was not competed by the initial RN comprehensive assessment within 5 days.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current: prescription and over-the-counter (OTC) Supplements; Herbal remedies; and Other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measures are implemented to manage the side effects.The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review, and interview. In 3 of 24 (12%) clinical records reviewed of patients with medication changes, the agency did not ensure the medication profile was updated, and the patient’s current medications were reviewed to identify actual or potential drug interactions. Agency policy # 2-004 (Revised 12/30/22) stated in part, “A drug regimen review will be performed at the time of initial and comprehensive assessment when updates to the comprehensive assessment are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication. The review will identify drug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy, duplicative drug therapy, and noncompliance with drug therapy.” Clinical Record 4: The patient elected hospice care on 5/4/23. The skilled nursing (SN) visit note dated 07/26/2023 documented that the patient started Keflex for a wound infection.There was no evidence that the medication profile was updated and the medication reviewed with the patient medication regimen as of 11/16/2023. Clinical Record 21: The patient elected hospice care on 8/16/23. The SN visit note dated 10/2/2023 documented arthritic cream working to manage pain. A review of the clinical record revealed no documentation of the cream used to manage pain. There was no evidence that the medication profile was updated to include documentation of the cream. There was no evidence the cream was reviewed as part of the patient’s medication regimen. Clinical Record 26: The patient elected hospice care on 11/14/23. The SN initial comprehensive assessment dated 11/14/2023, documented that the patient had a peripheral IV. The medication Fentanyl was ordered to be delivered intravenously hourly prn (as needed) six (6) times a day. A review of the medication profile revealed no documentation of saline and heparin to flush the peripheral IV as of 11/17/2023. The medication profile did not include documentation of the flush medications. There was no evidence the saline and heparin were reviewed as part of the patient’s medication regimen. During an interview on 11/17/2023, the Quality Manager stated that the medications were not on the medication profile and confirmed this with the in-patient manager.”

“It is required that each patient’s individualized written plan of care: Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, home observation visit, and interview. 7 of 26 (27%) records reviewed revealed the agency did not ensure that goals or interventions for patient or family were identified in the initial and updated comprehensive assessments. Document 4: No-9-017 The Plan of Care stated in part, “The written plan of care will contain, but will not be limited to, the following: Information from the patient updated comprehensive assessment and interdisciplinary group assessment of needs.” Clinical Record 3: The patient was admitted to hospice on 11/16/2023 with diagnoses of MS and UTI. The nursing assessment documented that the Foley catheter was discontinued by the facility on 05/16/2023. The updated plan of care documented that the patient continued with a Foley catheter. The observed visit on 11/16/2023 with the registered nurse revealed the patient did not have a Foley catheter. The plan of care had not been updated for all care of the patient. Clinical Record 4: The patient was admitted to hospice on 5/4/2023with diagnoses of Alzheimer’s, wound, and Diabetes Mellitus. The nursing assessment documented on 07/26/2023 that a wound was infected and treated with Keflex (an antibiotic). The plan of care was not updated to include interventions or goals for wound care except that the “facility will care for wounds but not how or how frequently the wound care will be done. or the location of the wound or how it was being treated. Clinical Record 13: The initial comprehensive assessment was documented on 08/11/2022 and identified problems of aspiration, fall risk, and pain The IDG plan documented on 08/11/2022 and updated every 2 weeks until revocation on 12/8/2022 does not document any interventions or goals for aspiration or fall risk. One of the goals was written on 8/11/2022: “Pain is managed at an acceptable level” (this was not measurable for a patient with Alzheimer’s who often has difficulty with words and is limited in speaking words as documented in nursing visits. Clinical Record 8: The initial comprehensive assessment was on 12/10/2022 and the initial IDG plan was developed and updated every 2 weeks. On 02/06/2023 the nursing visit note identified increased anxiety and sleep problems with an increase in Trazadone (anti-depressant), and on 01/06/2023 the patient developed an itch that would not resolve, and Benadryl was started, 02/03/2023, as documented on the nursing clinical notes. The patient developed a UTI (urinary tract infection) and was started CIPRO, (an antibiotic) on 3/9/2023 patient was identified as imminent. These problems were all identified but no interventions and goals were updated for these care problems. Clinical Record 20: The initial IDG plan of care documented a nutrition problem identified in the initial comprehensive assessment. An updated assessment dated 11/15/2023 documented increased trouble swallowing and risk of aspiration and that everyone should be using thick it. The intervention for nutrition documented instructions in dietary modification to improve overall nutrition and the diet documented soft but this was not specific to the thick it to prevent aspiration. This was not individualized for the patient. Clinical Record 21: The initial IDG plan of care updated every two weeks included a problem of incontinence. On 10/11/2023 prophylaxis treatment started for the prevention of multiple UTIs (urinary tract infections). The plan of care documented the antibiotic, but the goals and interventions were not updated to include the prevention of UTIs. Clinical Record 26: The Initial IDG plan of care documented on 11/14/2023 for a patient in GIP (General in-patient care) documented the intervention” RN may start IV/ SQ/PORT access. Assess every shift. Rotate the site if it shows signs and symptoms of infection” These interventions were not individualized and specific for the peripheral IV that was started, the need for catheter change, or frequency of catheter change, catheter size and length, and the dressing that would have been required to secured the IV, and frequency of change required. During an interview on 11/17/2023, the Quality Manager stated that all the goals were not updated.”

“It is required that each patient’s individualized written plan of care: Drugs and treatment necessary to meet the needs of the patient; (L549) This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 26 (12%) In clinical records reviewed the agency did not ensure that the plan of care included a full list of all medications that the patient was taking. Document 4: No 9-017 The plan of care stated in part, “The written plan of care will contain, but will not be limited to, the following: Drugs and treatments.” Clinical Record 3: The patient was admitted to GIP (General inpatient care) in the IPU (in-patient unity) on 08/18/2023 with an IV placed for antibiotics and pain medication. The order reads, “to maintain IV line.” There were no documented orders for flush of the peripheral IV and the plan was not updated with saline and heparin flush to maintain the peripheral IV line that included flush between mediations that were provided so the medication was not updated on the plan of care. Clinical Record 21: Nursing documented a note on 10/02/2023 that arthritic cream was managing the patients’ pain. The document did not document which cream was being used and the plan of care was not updated for all medications to include this cream. Clinical Record 26: A nursing comprehensive assessment documented on 11/14/2023 identified a peripheral IV ;. The patient was receiving as-needed pain medication of Fentanyl but no documentation of the saline and heparin that were being used to flush the catheter between doses. The patient was receiving about 6 doses a day. The plan of care was not updated to include the heparin and saline flushes.. The Quality Manager and IPU Manager stated that the peripheral IV was flushed with saline and heparin and the plans of care were not accurate for all medications that the patient used.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan: As frequently as the patient’s condition requires; but no less frequently than every 15 calendar days. A revised plan of care includes Information from the patient’s updated comprehensive assessment a record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review, document review, observation visit, and interview. In 1 of 26 (4%) In clinical records that were reviewed; the agency did not ensure that a revised plan of care was documented that included information from the patient’s updated comprehensive assessment and a record of the patient’s progress toward the outcomes and goals specified in the plan of care. Document 4: No 9-018 Interdisciplinary Group Plan of Care [revision date December 30, 2022} stated in part, “changes in patient clinical status, changes or initial issues with social, cultural, and physical environments that may present obstacles to effective interventions, evaluating patient/family progress toward achievement of expected outcomes and revising goals and objectives as needed, an increase or decrease in symptoms or acuity including nutritional status, pain management, condition of skin/presence/status of pressure ulcers.” Clinical Record 4 The patient clinical record identified a wound on 07/26/2023 on a clinical nursing assessment. There were no documented IDG (interdisciplinary meetings)updates on the wound from 07/23/2023 through 11/16/2023. This was an observed visit on 11/15/2023 with the nurse, staff 14. The observed wound was on the left foot on the toe next to the great toe, to the bone in depth. This wound was identified in July of 2023 and had progressed with no documented evidence of the patient’s progress toward goals or the status of the wound. The Quality Manager on 11/17/2023 agreed the update on the wound was not documented.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable Hand hygiene; Use of gloves, mask, eye protection, or face shield depending on anticipated exposure; Safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids. Safe handling of soiled items in the patient’s care environment; Other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by document review, interview and observation. In 2 of 7 (29%) In the observed visit the agency did not ensure all infection control measures were followed including hand hygiene. Document 4: No. 7-009 Hand Hygiene which stated in part, “Hand decontamination using an alcohol-based hand rub should be performed: Before having direct contact with patients, after contact with a patients intact skin (when taking a pulse blood pressure or lifting a patient, when moving from a contaminated body site to a clean body site during patient care. After contact with inanimate objects in the immediate vicinity of the patient. After removing gloves. Home Visit 1: Observed a visit on 11/15/2023 with a Chaplain (staff 6) in the patient’s home. The chaplain during the visit commented on the caregivers tee-shirt and patted the caregiver on the back. After which, the chaplain in speaking with the patient grabbed and held the bedrail while conversing with the patient. After minutes in conversation, chaplain offered prayer, which the patient accepted. Chaplain embraced the patient’s hands and lead a prayer. During this sequence of events, proper hand sanitation per the agency policy was not followed. The chaplain did not sanitize hands before having direct contact with the patient nor after contact with a patient’s skin. Home Visit 5: Observed a visit on 11/15/2023 with a nurse (staff 14) in a skilled nursing facility, with a bed-bound patient who had a wound. In the patient room, the nurse moved a bedside table from the middle of the room placed a plastic bag on it and placed his bag on it. The equipment was removed with no hand sanitization. The thermometer and blood pressure were assessed. The stethoscope was around the nurse’s neck, it was removed to check blood pressure and assess cardiac, respiratory, and bowel sounds and placed back around the neck. Hands were sanitized, gloves donned, and right-toe dressing removed and discarded. The wound was cleaned with saline and gauze, but no hand sanitization was completed prior to cleaning. The nurse paused as then out of a plastic bag removed a Q- tip to measure the wound, no hand sanitization was performed. The nurse did not have supplies to dress the wound so removed gloves, sanitized, and went to talk to the staff about the correct wound care. The nurse removed from her medication cart the dressing and antibiotic ointment in a cup and handed it to the nurse who took it (no one sanitized) walked to the patient’s room, placed gloves on his hand, no hand sanitization, and dressed the wound. (During the measurement and vital sign assessment, a pen was removed from his pocket 5 times, and wrote the results on a pad of paper with no hand sanitization.) a pen was removed from the chest pocket and measurements were written on the pad with no hand sanitization. wound care was completed, and dirty supplies were placed in a plastic bag. A pen was removed from the nurse’s pocket and the date was written on the dressing with no hand sanitization. Hands were washed with soap and water and the dirty supplies bagged were taken to the dirty utility room, with no hand sanitization., The hospice nurse went to the staffing area and removed a binder from the records to write notes. No hand sanitization. During an interview on 11/16/2023, the administrator and quality nurse stated that the hand hygiene policy was not followed.”

“It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by clinical record review and interview. 2 of 2 (100%) clinical records reviewed revealed the agency did not ensure that RN supervision of a licensed practical nurse occurred. The policy manual did not contain a policy that included the time frame for the LPN supervision by the RN. Clinical Record 8: The patient was admitted on 12/10/2022, with a wound vac, unspecific protein caloric malnutrition. The first LPN visit was completed on 01/17/2023 and a second visit on 03/8/2023. There was no documented evidence of RN supervision of the LVN at the time of the patient’s death on 03/09/2023, 81 days. Clinical Record 4: This patient was admitted on 5/4/2023 with Alzheimer’s, a wound, and diabetes mellitus. The first was LVN visit was completed on 06/14/2023 with an additional visit on 11/02/2023. There was no documented evidence of RN supervision of the LPN as of this review on 11/16/202, 141 days. During an interview on 11/16/23, the Quality Manager stated that the process was to document LVN supervision every 30 days.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 23 (4%) clinical records reviewed of patients receiving hospice aide services, the agency did not ensure the hospice aide received specific written patient care instructions. Clinical Record 13: The hospice aide care plan documented on 08/11/2022 assigned the hospice aide the task of shower (3) three times a week. The nurse visit note dated 10/19/2022 documented the patient was a fall risk and wheelchair-bound and required maximum assistance for transfer. The hospice aide care plan did not document instructions for transferring the patient or safety instructions as of the patient’s discharge on 12/08/2022. During an interview on 11/17/2023, the Administrator and Regional Manager stated that the direction for transfer should have been updated on the plan of care.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 26 (4%) the clinical records reviewed in which additional verbal orders were needed, the agency did not ensure all verbal orders were documented. Clinical Record 4: The patient elected the the hospice benefit on 5/4/2023 with a diagnosis of Alzheimer’s wound, and diabetes mellitus. An observed nursing visit on 11/15/2023 in which the nurse provided wound care. The nurse stated after he removed the foot dressing he was not sure what to put back on the wound. The plan of care had no documented wound care and no orders for wound care. After the visit and on 11/16/2023 the order for wound care was documented as: “wound care, clean wound, pat dry, apply muciporen and border dressing”. The order lacks location of the wound and frequency of wound care. During an interview on 11/16/2023, the quality manager on 11/16/2023 stated that the location and frequency were missing from the wound care order,”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: a copy of the hospice discharge summary and the patient’s record if requested. This standard was not met as evidenced by clinical record review, document review, and interview. In 2 of 2 (100%) clinical records reviewed of discharged patients, the agency did not forward the patient’s attending physician a copy of the hospice discharge summary. Agency policy #1-025 (effective 12/30/22] stated in part, “A copy of the discharge summary will be sent to the attending physician. If requested, the patient’s clinical record will be provided.” Clinical Record 13: The patient elected hospice care on 3/19/2023. The nurse documented that the patient revoked the hospice care benefit on 12/08/22 to seek aggressive treatment. A clinical record review revealed no evidence that the discharge summary was sent to the patient’s primary care physician post-discharge. Clinical Record 7: The patient elected hospice care on 3/29/23 with a diagnosis of Alzheimer’s Disease and revoked the hospice care benefit on 4/11/23 to seek aggressive treatment. A clinical record review revealed no evidence that the discharge summary was sent to the patient’s primary care physician post-discharge. During an interview and a joint record review on 11/17/23, the Quality Director stated that there was no documentation that the summary was sent to the physician.”

“It is required that the hospice ensures that the durable medical equipment (DME) is safe and in working order as intended for use in the patient’s environment. The hospice ensures that the manufacturer’s guidelines for performing routine maintenance and preventive maintenance are followed. The hospice ensures that repair and maintenance policies are developed when the manufacturer’s guidelines for a piece of equipment do not exist. The hospice may use persons under contract to ensure the maintenance and repair of durable medical equipment. This standard was not met, as evidenced by interviews and observations. During a tour of the Inpatient Hospice Unit (IPU), it was observed that the agency did not ensure that the durable medical equipment was in safe working order and that it was properly maintained for immediate use in patient care needs. LSC inpatient tour on 11/16/2023 with the Inpatient Manager and the Facilities Maintenance Director revealed the following items lacked routine maintenance documentation to ensure that equipment was safe and sanitary for utilization. Further interviews revealed and confirmed that there was confusion on how some of the concentrators were in the building while others had been donated to the organization and put into the storage closet. 1) The storage closet by patient room #2, which served as oxygen storage, contained two O2 concentrators. Upon interview with the IPU manager, the concentrators were ready for usage, and staff would take them to the patients in need as necessary. There was no tagging for inspection/bagging for sanitation reasons nor mechanism/markings to indicate whether the concentrators were ready for patient use. Inspecting the filters in each machine, I found both filters contained dust and dirt particles and needed cleaning. In addition, the concentrators appeared dirty and sticky to the touch, as if something had been whipped on them but not thoroughly cleaned off. The IPU manager agreed that the concentrators were not ready for usage and that the filters were “very dirty’. 2) In patient rooms, which were empty at the time of the observed visit on 11/16/2023, #5 and #3 were identified as cleaned and ready for admission, but they were observed as having unclean equipment for use. Room # 5 and Room #3 had oxygen concentrators with dirty filters in the machine and no label that the oxygen equipment was sanitized. The oxygen concentrators were not covered to protect them from dust and other airborne contaminants. 3) There were no DME/Concentrator maintenance logs to confirm that a process had been utilized to ensure the equipment was in safe working order. The IPU manager attempted to gather what resource logs were available. However, none were produced for the O2 concentrator oversite. Per interview and confirmation with the IPU manager and facility maintenance director, they had a detailed step-by-step maintenance schedule for all facility areas; however, it was not currently in use. LSC inpatient tour on 11/16/2023 with the Inpatient manager and the facilities maintenance director revealed the following items lacked documentation of routine maintenance to ensure that equipment was safe and sanitary for utilization. Further interview revealed and confirmed that there was confusion on how some of the concentrators were in the building while others had been donated to the organization and put into the storage closet. 1.) The storage closet by patient room #2 which served as oxygen storage contained two O2 concentrators. Upon interview with the IPU manager, the concentrators were ready for usage and that staff would take them as necessary to the patients in need of them. There was no tagging for inspection/bagging for sanitation reasons nor mechanism/markings to indicate whether the concentrators were ready for patient use. Inspecting the filters in each machine, both filters contained dust and dirt particles and needed cleaning. In addition, the concentrators appeared dirty and sticky to the touch as something had been whipped on them but not completely cleaned off. The IPU manager agreed that the concentrators were not ready for usage and that the filters were “very dirty’. 2.)Patient rooms 5 and 3 indicated by the inpatient manager during the facility tour on 11/16/2023 that the room were fully ready to receive new patients. Each room had O2 concentrators that revealed dirty filters and both were not properly tagged for inspection /bagged for sanitary conditions, nor marked for ready usage. 3.) There were no DME/Concentrator maintenance logs to confirm that a process had been utilized to ensure that the equipment was in safe working order. The IPU manager attempted to gather what resources logs were available however, none were produced for O2 concentrator oversite. Per interview and confirmation with the IPU manager and facility maintenance director they did produce a very detailed step by step maintenance schedule for all arears of the facility, however it was not currently is use.”

“It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 17 (6%) Clinical Records reviewed for patients that were at skilled facilities, the agency did not ensure that all plans of care were detailed for who provides the patient care the facility staff or the hospice, or shared duties. Clinical Record 4: During the observed visit on 11/15/2023, the nurse was unaware of what the wound care was though he had removed the dressing, he cleaned the wound then returned to the facility nursing desk to ask the staff for the order for wound care. The hospice plan of care had an intervention stated that the facility would participate in the hospice plan of care. The intervention for specific wound care for a wound located on the left foot toe next to the great toe in July of 2023 was not documented. On 11/16/2023 a wound care order was documented for cleaning and dressing coverage but lacked the detail for who would provide the wound care, the location of the wound, and the frequency of the wound care. It was not specific for who would provide the wound care. With the director of quality on 11/17/2023 stated that the detail of who provided wound care was not on the plan of care.”

“It is required that the hospice designates a member of each Interdisciplinary Group who is responsible for a patient/resident in a SNF/NF or ICF/IDF. The designated IDG member: Provides overall coordination of care of the patient/resident, working with the facility representative staff;. This standard was not met as evidenced by interview and observation. In 1 of 4 (25%) observed visits at skilled facilities the agency did not ensure coordination of care, specifically wound care for the resident was provided and documented. Clinical Record 4: During the observed visit on 11/15/2023, the hospice nurse (staff 14) was unaware of the wound care orders when removing the foot dressing and cleansing the wound. he had to return to the nursing staff desk to ask the staff what the order for wound care. Additionally, on 10/10/2023 a chest x-ray had been ordered for bruising and swelling around the ribs, no update for this was documented in the IDG from this as of review 11/16/2023. No updates on the wound were documented with the wound identified in July of 2023. The nurse was unaware of the wound care order during the visit and the clinical record did not document coordination related to the wound or follow-up with the chest x-ray that had been ordered. During an interview on 11/15/2023, the director of quality confirmed the coordination of care was not documented. The hospice nurse stated on 11/15/2023, “ I was not sure what the wound care is, I’ll have to check with the facility staff. I’m not sure of what’s current for the patient” because of working nights for the last 2 weeks.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: Hospice election form and any advance directives. This standard was not met as evidenced by interview and observation. In 1 of 4 (25%) Observed visits at a skilled nurse facility, the agency did not ensure that all documents were maintained at the facility. Home Visit 5: Observed nursing visit (staff 14) on 11/15/2023. The nurse identified the binder of patient information that was maintained for the facility to keep care coordinated. The hospice election of benefit was not in the folder or the binder of information. There was no evidence the advance directives were in the folder or binder of patient of patient information. The hospice nurse and the facility nurse could not locate these documents. During an interview, the hospice nurse case manager for the facility stated that it must not be there, referring to the benefit of election and advance directives, and that he would have to get the copies and get them in the binder.”

“It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. (L795) Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by document review and interview. In 1 of 5 (20%) In contracts that involved staff who would provide direct patient care, the agency did not ensure the language to obtain criminal background checks was documented on the medical director’s contract. Document 4: Policy Bo. HR 11 stated in part, “If the decision is made to offer a position to an applicant, the action is noted in the electronic recruiting system and a contingent, verbal job offer is made. HR is notified and launches the criminal history background check, electronic reference checking system, searches all associated date ranks by license for verification of good standing (OIG, Medical Board, BON, BOSW, etc.) initiates the drug testing and if the position is clinical, a lift assessment will be completed. Contract 1: The medical director contract signed on 12/18/2018 did not document specific language to include a criminal background check, The contract did state that the Provider shall: maintain a valid and unrestricted license to Practice Medicine in the state of XXXXX. The agency did document that criminal background checks were completed for all of the staff record members including the medical director that were reviewed. with the Quality Director who consulted with the lead for contracts and agreed that all backgrounds were checked but the specific language was not on the contract.”

“It is required that the inpatient hospice facility addresses real or potential threats to the health and safety of patients, hospice staff, visitors, others, and property. This standard was not met, as evidenced by interviews and observations. The Life Safety Code (LSC) inpatient tour on 11/16/2023 with the Inpatient (IPU) Manager and the Facilities Maintenance Director revealed potential threats to the safety of patients and others not addressed assuring an adequate means of egress for patient and staff evacuation. The Fire Exit Door, identified as the East stairwell exit door and is also the door through which the evacuation route is indicated, blocked the traffic flow on the staircase path by having remodeling materials and mixing grout bags on the floor of the stairway landing between story two and story 1. The Facility Maintenance Director said that a project was being completed. However, supplies were not to be left in a stairway blocking egress. The alcove entrance to the family room kitchen had a small four-legged table with literature, propping the door open and blocking the means of egress. This was the only entrance/exit to the room itself. The IPU Manager and the Facility Director said that the table blocked the means of egress. Document Review: Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1. Life Safety Code 101, 2012 edition. LSC inpatient tour on 11/16/2023 with the Inpatient manager and the facilities maintenance director revealed the following items lacked proper oversight for ensuring the integrity of egress. 1.) Fire Exit Door identified as the East stairwell exit door and is also the door through which the evacuation route is indicated, blocked the traffic flow on the the staircase path by having remodeling materials and mixing grout bags on the floor of the stairway landing between story 2 and story 1. Facility maintenance director stating that a project was being completed however, supplies were not to be left in a stairway blocking egress. 2.) The alcove entrance to the family room kitchen had a small 4 legged table with literature on it propping the door open blocking the means egress, This was the only entrance/exit to the room itself. The IPU manager and the facility director both stated that the means of egress was blocked by the table 3.) Four door stops were found in various locations throughout the facility by various doors that evidently were utilized to be propped open at times. This was confirmed in conversation by the IPU manager. One stop was utilized in the whirlpool room that left the doors open to the main patient corridor. This was promptly and corrected by the IPU manager. 4.) 6.) During the tour of the “ready and available rooms” (3 and 6) with the IPU manager and the maintenance director, small personal refrigerators are provided, one in each room. Both of the refrigerators did not contain an temperature control log. In room 6, the refrigerator did not provide a thermometer inside it to register the temperature. In room 3, there was a thermometer however there was an open bag of candy still in it. The IPU manager confirmed that both rooms were not ready for new patients and immediately had the housekeeping staff come to detail the rooms.”

“It is required that a hospice-operated inpatient care facility complies with all applicable federal, state, and local health and safety codes, including the applicable provisions of the Life Safety Code (LSC) of the National Fire Protection Association NFPA 101, Life Safety Code 2012 edition; and, (L827-418.110(d)) a)Tentative Interim Amendments (TIA) 12-1, TIA 12–2, TIA 12–3, and TIA 12–4; and, the Health Care Facilities Code NFPA 99, 2012 edition and Tentative Interim Amendments TIA 12–2, TIA 12–3, TIA 12–4, TIA 12–5, TIA 12–6 – except Chapters 7, 8, 12, and 13 that do not apply to hospice. (L828-418.110(e)). This standard was not met as evidenced by document review, interview and observation. The LSC (Life Safety) inpatient tour on 11/16/2023 with the Inpatient (IPU) Manager and the Facilities Maintenance Director revealed the following items that did not comply with the federal, state, and local health and safety codes. 1) One ceiling tile inside the smoke compartment containing four patient rooms had a hole directly opening into the attic space of the smoke compartment. As revealed through an interview, the facility maintenance director stated that the “tile was missed after they had been working on a re-wiring project.” Document Review:2012 EXISTING Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. The size of the compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier. 19.3.7.1, 19.3.7.2, Life Safety Code 2012 edition. 2) The Smoke compartment wall in the patient corridor separating rooms 1 and 2 from the rest of the unit did not meet LSC regulations, as evidenced by unsealed piping between the corridors, which contained blue and white wiring. The facility director stated that he “wished we had not seen that,” but he said he knew it was not in compliance. Document Review:2012 EXISTING Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. The size of the compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier. 19.3.7.1, 19.3.7.2, Life Safety Code 2012. 3) The Electrical Room Door, as confirmed by the rating on the door hinge, indicated a 20-minute fire resistance rating; however, this door, per LSC, should have a 2-hour fire resistance rating. Document Review: Vertical Openings – Enclosure, If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating. Life Safety Code 2012. 4) The Fire door east stairwell exit and the Electrical room door, per LSC, should have annual inspections documented in writing and maintained with the routine facility logs. Upon interview and document review, it was confirmed that annual door inspections for these two doors had not been documented. 5) The storage closet by patient room #2, which served as oxygen storage, revealed that two containers were not stored in the required racks per LSC regulations. The Inpatient Director and the facility maintenance director confirmed this. 6) The storage closet by patient room #2, which served as oxygen storage, revealed there were 18 containers of oxygen, including two containers that were not adequately secured and unlabeled as if they were full or empty tanks. The closet contained no signage nor a separation in the storage system to indicate full/empty containers. Document Review: Gas and Vacuum Piped Systems – Central Supply System Identification and Labeling Containers, cylinders, and tanks are designed, fabricated, tested, and marked in accordance with 5.1.3.1.1 through 5.1.3.1.7. Locations containing only oxygen or medical air have doors labeled with “Medical Gases, NO Smoking or Open Flame.” Locations containing other gases have doors labeled “Positive Pressure Gases, NO Smoking or Open Flame, Room May Have Insufficient Oxygen, Open Door and Allow Room to Ventilate Before Opening.” 5.1.3.1, 5.2.3.1, 5.3.10 (NFPA 99). 7) The storage closet by patient room #2, which served as oxygen storage, revealed two free-standing oxygen concentrators that were not tagged/bagged as being ready for patient usage. Document Review: Gas and Vacuum Piped Systems – Central Supply System Identification and Labeling Containers, cylinders, and tanks are designed, fabricated, tested, and marked in accordance with 5.1.3.1.1 through 5.1.3.1.7. 5.1.3.1, 5.2.3.1, 5.3.10 (NFPA 99). 8) The storage closet by patient room #2, which served as oxygen storage, revealed a mattress overlay that was stored in an upright position behind a metal shelving unit which extended into the required 18” of clearance space required by LSC and was within inches of touching the ceiling tile, required. All items were confirmed through observation and interviews with the Inpatient (IPU) Manager and the Facilities Maintenance Director who participated in the tour. They said that they had work to bring things to code. LSC (Life Safety) inpatient tour on 11/16/2023 with the Inpatient manager and the facilities maintenance director revealed the following items that did not comply with the federal, state, and local health and safety codes during the facility tour. All items were confirmed through observation and interviews with the Inpatient manager and the facilities maintenance director who participated in the tour. 1.) The Fire Exit Door identified as the East stairwell exit door and was also the door through which the evacuation route was indicated, had incorrect latching material as evidenced by the door having a magnetized mechanism rather than a fire latch assembly mechanism. 2.) The Fire Exit Door identified as the East stairwell exit door and is also the door through which the evacuation route is indicated, displayed a fire-resistance rating of one and a half hours on the hinged side of the door, rather than the required fire-resistance rating of two hours. 3.) The alcove beyond and to the right side from the Fire Exit Door east stairwell exit, was not covered by an adequate sprinkler system as evidenced by no sprinkler head being installed in the area and the next available sprinkler head was beyond the required measurements to ensure patient and facility safety. 4.) One ceiling tile inside the smoke compartment containing four patient rooms had a hole directly opening into the attic space of the smoke compartment. As revealed through an interview, the facility maintenance director stated that the “tile was missed, after they had been working on a re-wiring project.” 5.) The Smoke compartment wall in the patient corridor separating rooms 1 and 2 from the rest of the unit did not meet LSC regulations as evidenced by unsealed piping between the corridors which contained blue and white wiring. The facility director stated that he “wished we had not seen that”, but he stated he knew it was not in compliance. 6.) The Electrical Room Door as confirmed by the rating on the door hinge, indicated a 20-minute fire resistance rating however this door per LSC should have a 2-hour fire resistance rating. 7.) The Fire door east stairwell exit and the Electrical room door per LSC should have annual inspections documented in writing and maintained with the routine facility logs. It was confirmed upon interview and document review that annual door inspections for these two doors had not been documented. 8.) The storage closet by patient room #2 which served as oxygen storage, revealed that 2 containers were not stored per LSC regulations in required racks. This was confirmed by the Inpatient Director and the facility maintenance director. 9.) The storage closet by patient room #2 which served as oxygen storage, revealed there were 18 containers of oxygen, including the two containers not properly secured, which were unlabeled as it they were full or empty tanks. The closet contained no signage nor a separation in the storage system to indicate full/empty containers. 10.) The storage closet by patient room #2 which served as oxygen storage, revealed two free-standing oxygen concentrators which were not tagged/bagged as being ready for patient usage. 11.) The storage closet by patient room #2 which served as oxygen storage, revealed a mattress overlay that was stored in an upright position behind a metal shelving unit which extended into the required 18” of clearance space required by LSC and was within inches of touching the ceiling tile, required.”

“It is required that hospice inpatient facilities provide a sanitary environment by following current standards of practice, including nationally recognized infection control precautions and avoiding sources and transmission of infections and communicable diseases. This standard was not met, as evidenced by interviews and observations. The Life Safety Code (LSC) inpatient tour on 11/16/2023 with the Inpatient (IPU) Manager and the Facilities Maintenance Director revealed the following: 1.) The ice machine in the family dining area was not clean, as evidenced by the calcified build-up on the retention tray/rack and machine edges around the retaining tray. The IPU Manager confirmed that the machine was dirty. A cleaning log could not be found when the ice machine was last cleaned. 2.) An open container of applesauce was in the family refrigerator, unlabeled as to when it had been opened. 3.) The storage closet by patient room #2, which served as oxygen storage, contained two O2 concentrators. Upon interview with the IPU Manager, the concentrators were ready for usage, and staff would take them as necessary to the patients in need of them. There was no tagging/bagging mechanism/marking to indicate whether the concentrators were ready for patient use. Inspecting the filters in each machine, I found both filters contained dust and dirt particles and needed cleaning. The IPU Manager agreed that the concentrators were not ready for usage and that the filters were “very dirty’. 4.) Patient rooms #5 and #3 indicated by the IPU Manager during the facility tour on 11/16/2023 that the rooms were entirely ready to receive new patients. Each room had O2 concentrators that revealed dirty filters and both were not adequately tagged/bagged indicating the concentrators were inspected and prepared for usage. 5.) The two O2 concentrators in the O2 storage closet and the O2 concentrators in rooms #3 and #5 were all visually dirty, and two had a greasy/sticky surface to the touch. All four O2 concentrators were not tagged/bagged with dates of cleaning or inspection nor fully covered for protection prior to usage. The IPU Manager confirmed the findings during the tour by interview and visual inspection. 6.) During the tour of the “ready and available rooms” (#3 and #5) with the IPU Manager and the Facility Maintenance Director, small personal refrigerators are provided, one in each room. Neither of the refrigerators contained a temperature control log. In-room 5, the refrigerator did not provide a thermometer to register the temperature. In-room 3, there was a thermometer; however, an open bag of candy was still in it. The IPU Manager confirmed that both rooms were not ready for new patients and immediately had the housekeeping staff come to detail the rooms. LSC inpatient tour on 11/16/2023 with the Inpatient manager and the facilities maintenance director revealed the following items which lacked proper sanitary process and lacked standard infection control processes to avoid sources of transmission of infections. All items were confirmed through observation and interviews with the Inpatient manager and the facilities maintenance director who participated in the tour. 1.) The ice machine in the family dining area was not clean as evidenced by the calcified build-up on the retention tray/rack and machine edges around the retaining tray. It was confirmed by the inpatient manager that the machine was dirty. A cleaning log could not be found as to when the ice machine had been last cleaned. 2.) An open container of applesauce was in the family refrigerator unlabeled as to when it had been opened. 3.) The storage closet by patient room #2 which served as oxygen storage contained two O2 concentrators. Upon interview with the IPU manager, the concentrators were ready for usage and staff would take them as necessary to the patients in need of them. There was no tagging/bagging mechanism/marking to indicate whether the concentrators were ready for patient use. Inspecting the filters in each machine, both filters contained dust and dirt particles and needed cleaning. The IPU manager agreed that the concentrators were not ready for usage and that the filters were “very dirty’. 4.) Patient rooms 5 and 3 indicated by the inpatient manager during the facility tour on 11/16/2023 that the rooms were fully ready to receive new patients. Each room had O2 concentrators that revealed dirty filters and both were not properly tagged/bagged indicating the concentrators were inspected and ready for usage. 5.) The two O2 concentrators in the O2 storage closet as well as the O2 concentrators in rooms 3 and 5, all were visually dirty and two of them had a greasy/sticky surface to the touch. All 4 were not tagged/bagged with dates of cleaning or inspection nor fully covered for protection prior to usage. The IPU manager confirmed the findings during the tour by interview and visual inspection. 6.) During the tour of the “ready and available rooms” (3 and 6) with the IPU manager and the maintenance director, small personal refrigerators are provided, one in each room. Both of the refrigerators did not contain a temperature control log. In-room 6, the refrigerator did not provide a thermometer inside it to register the temperature. In room 3, there was a thermometer however there was an open bag of candy still in it. The IPU manager confirmed that both rooms were not ready for new patients and immediately had the housekeeping staff come to detail the rooms.”

“It is required that hospice inpatient facilities have a quantity of clean linen available in sufficient amounts for all patient uses at all times. Linens are handled, stored, processed, and transported in such a manner to prevent the spread of contaminants. This standard was not met, as evidenced by interviews and observations. The Life Safety Code (LSC) Inpatient Hospice Unit tour on 11/16/2023 with the Inpatient Hospice Manager revealed the agency did not ensure the available clean linen was stored in a manner to prevent the spread of infection. The clean linen double-door closet was partially closed. Upon opening the doors, a stuffed plastic bag of donated towels and washcloths was shoved into the top right-hand shelf and was too full to be contained on the shelf itself. It slipped partially off the shelf and kept the door from completely shutting. In addition, the rolling 6-foot linen cart had a rolling screen front to protect the linen. This screen was not closed. The Inpatient Hospice Manager agreed that the storage in the linen closet included donated items and that storage space was in short supply. Everything was confirmed through observation and interview with the Inpatient Hospice Manager who participated in the tour. LSC inpatient tour on 11/16/2023 with the Inpatient manager revealed the following items that did not comply with the federal, state, and local health and safety codes during the facility tour. All items were confirmed through observation and interview with the Inpatient manager who participated in the tour. The storage of clean linen was compromised to infection as evidenced by the clean linen double door closet was not completely closed. Upon opening the doors, a stuffed plastic bag of donated towels and washcloths was shoved into the top right-hand shelf and was too full to be contained on the shelf itself slipped partially off the shelf, and kept the door from completely shutting. In addition, the rolling 6-foot linen cart contained a rolling screen front to protect the linen. This screen was not closed. The IPU manager agreed that this was not a properly contained linen closet and that storage space was in short supply.”

“It is required that the hospice inpatient facility provides meals to each patient that are palatable, attractive, and served at the proper temperature; food is available 24/7 to respond to patients’ needs or requests. The Interdisciplinary Group (IDG) is kept informed of the patient’s response to their prescribed diet. This standard was not met as evidenced by document review, interview and observation. During interviews and observations conducted during a tour of the inpatient hospice unit, the agency did not ensure that food was served to patients at the proper temperature. The hospice contracts for food service through the LTC (long-term care) facility in the building in which the facility is located. Logs from the LTC kitchen were reviewed and reflected all meal items’ temperatures, both hot and cold items. The food was transported to the inpatient hospice unit from the LTC kitchen in an unheated nor chilled transport cart. Food was delivered to the facility, and the facility staff was responsible for distributing the food. The hospice staff does not record or have a process to check the food items’ temperature before taking the food tray to the patients. The hospice contracts for food service through the LTC (long-term care) facility in the building in which the facility is located. Logs from the LTC kitchen were reviewed and reflected all meal items’ temperatures, both hot and cold items. The food was transported to the hospice unit from the LTC kitchen in an unheated nor chilled transport cart. Food was delivered to the facility and the facility staff was responsible for distributing the food. The hospice staff does not record or have a process to check the temperature of the food items prior to taking the food tray to the patients.”