St. Gabriel’s Hospice and Palliative Care

“Based on record review and interview, the agency failed to exercise the patient’s rights and respect for property and person, for 1 (Patient #2) of 4 patients in that; Patient #2 was admitted to hopsice by an individual that was not a legal representative designated by the patient to the extend allowed by state law. The failure placed the patients’ at risk of decisions being made about their medical care by persons who were not authorized to make decisions according to the patients’ rights. Review of Texas Health and Safety Code, Chapter 166, 166.002, effective 9/1/1999 read in part; “Definitions...(11) Medical Power of Attorney under Subchapter D means a document delegating to an agent authority to make health care decisions executed or issued under Subchapter D...Subchapter D...Sec. 166.039. Procedure When Person Has Not Executed Or Issues A Directive and is incompetent or incapable of communication. (a) If an adult qualified patient has not executed or issued a directive and is incompetent or otherwise mentally or physically incapable of communication, the attending physician and the patient’s legal guardian or an agent under a medical power of attorney may make a treatment decision that may include a decision to withhold or withdraw life-sustaining treatment from the patient. (b) If the patient does not have a legal guardian or an agent under a medical power of attorney, the attending physician and one person, if available, from one of the following categories, in the following priority, may make a treatment decision that may include a decision to withhold or withdraw life-sustaining treatment: (1) the patient’s spouse; (2) the patient’s reasonably available adult children; (3) the patient’s parents; or (4) the patient’s nearest living relative...” Patient #2:Review of Patient #2’s clinical record revealed a Plan of Care dated 7/29/2026. The Plan of Care indicated that Patient #2 started on the hospice’s services on 7/29/2026. The Plan of Care listed Severe Protein-Calorie Malnutrition (life-threatening form of undernutrition caused by a significant deficiency in protein and calorie intake or absorption) at the terminal diagnosis. The Plan of Care listed Down Syndrome (present from birth condition with some degree of limitation of intellectual ability, social, and practical skills), Schizophrenia (Mental health condition with serious impact on personal, interpersonal, and occupational functioning, with hallucinations, delusions, eccentric speech and behavior), Chronic Debility (muscle weakness and weight loss), Osteomyelitis (serious infection of the bone), and recurrent aspiration pneumonia (repeated lung infections caused by inhalation of foods, liquids, or stomach contents) as comorbid diagnoses. Review of the consents in Patient #2’s clinical record indicated that the consents for hospice services were signed on 7/29/2026 by Signer 1, who was not identified to be Patient #2’s family member. Signer 1 was not a family member of Patient #2. Review of Patient #2’s clinical record revealed a Living Will. The Living Will was a multi-page document. The Living Will listed Signer 1 as Successor Power of Attorney for Patient #2 and was signed by Patient #2 on 6/11/2003. The document contained a Health Care Agent/Designation of Surrogate Proxy which was listed as Proxy 1, which was signed on 8/10/2015 by Patient #2 and two witnesses. Signer 1 was not listed as a Successor Health Proxy. During an interview on 8/11/2026 at 3:34 PM with the Alternate Director of Nursing, Executive Director, and Hospice Liaison the surveyor discussed the admission of Patient #2. The Surveyor asked what had transpired from when they first heard of Patient #2 until discharge. Executive Director informed the Surveyor that a referral was received from the hospital in the portal; the Hospice Liaison met with Patient #2 and Signer 1; and Signer 1 signed the consents for hospice at that time. The Surveyor asked when did the hospice get the copy that Signer 1 was the medical power of attorney. Executive Director stated, “At the time of the consent signing.” The Surveyor asked who reviewed the medical power of attorney documents. Executive Director stated, “We all do, (Director of Nursing, Alternate Director of Nursing, and Executive Director).” Executive Director informed the Surveyor that it had been noted in the hospital chart that Patient #2’s medical power of attorney was Signer 1. The Surveyor asked who gave the hospice a copy of the medical power of attorney. Executive Director informed the Surveyor that the Executive Director would have to ask. The Surveyor asked who reviewed and approved the medical power of attorney. Executive Director informed the Surveyor that the Executive Director, the Director of Nursing, and the Alternate Director of Nursing approved the medical power of attorney document. The Surveyor asked what happened while Patient #2 was on services. Executive Director informed the surveyor that Patient #2 was admitted by Registered Nurse C; Patient #2 was on services for about 4 days; the hospice had received a phone call on 8/3/2026 at 1:00 AM that Phone Caller told them that Patient #2 wanted to be kept alive by all means necessary, Patient #2 would not have wanted to die; Phone Caller was informed the hospice was following the medical power of attorney; Phone Caller had told them that Phone Caller was going through the process to be Patient #2’s guardian; and Phone Caller was not satisfied with the answer or accepting any of this. Executive Director informed the Surveyor that Executive Director had Alternate Director of Nursing check in with the group home that Patient #2 lived at. The Alternate Director of Nursing informed the surveyor that Group Home Owner was told that the hospice could not stop Group Home Owner from sending Patient #2 to the hospital, but that it would be unauthorized. Executive Director said that the hospice tried to reach Signer 1 but was unsuccessful. The Alternate Director of Nursing stated that Patient #2 went to the hospital and died 20 minutes after arriving. The Surveyor asked where it showed on the medical power of attorney document that Signer 1 had health proxy. Executive Director informed the Surveyor that it was on the last page with the power of attorney. The Surveyor asked if Power of Attorney was the same as the Medical Power of Attorney. Executive Director stated, “No.” The surveyor asked what the process and policy of the agency was if an incapacitated adult was admitted to the hospice, what do you expect to see or have. The Executive Director informed the surveyor they would expect to see next of kin or medical power of attorney. The surveyor asked if the incapacitated adult did not have next of kin or power of attorney specified, what would you expect to see. Executive Director stated, “I would refer to the policy book, because it would be unusual circumstance.” The Executive Director informed the surveyor that it was not brought to the Executive Director’s attention that Patient #2 did not have a medical power of attorney and wanted to add Hospice Liaison to the call. The Surveyor asked when Hospice Liaison first saw Patient #2, what was Patient #2’s status. Hospice Liaison informed the surveyor that Patient #2 could not verbalize wishes, could not say name or wants. The Surveyor asked who had been present when Hospice Liaison had the consent papers signed. Hospice Liaison informed the Surveyor that the physician, Signer 1, Group Home Owner, and Hospice Liaison were present at the meeting at Patient #2’s bedside. The Surveyor asked whether Hospice Liaison had been in a meeting attempting to find a next of kin for Patient #2. Hospice Liaison informed the Surveyor that the hospital had tried to reach out to Proxy1, Next of Kin 1. The hospital found Signer 1. The Surveyor asked if Hospice Liaison had seen where the document indicated that Signer 1 was made health proxy or medical power of attorney. Hospice Liaison stated, “One of the last pages.” The Surveyor asked if Hospice Liaison had read the document. Hospice Liaison stated, “I never saw a medical power of attorney document. I saw a Living Will that had Proxy 1 and Signer 1’s names. The Surveyor asked if anyone had been able to contact Proxy 1 or Next of Kin 1. Hospice Liaison stated, “(Proxy 1) had passed and (Next of Kin 1) had passed away too.” The Surveyor asked who was making decisions for Patient #2 after Proxy 1 and Next of Kin 1 had passed away. Hospice Liaison informed the surveyor that Group Home Owner and group home team. The Surveyor asked if Hospice Liaison had discussed why Signer 1 was not involved with Patient #2’s care at that time. Hospice Liaison had informed Hospice Liaison that Signer 1 was unaware of who was in line next and unaware of who was taking care of Patient #2 since Proxy 1 had passed away. During an interview on 8/12/2026 at 9:55 AM with the Administrator, the Administrator provided documents regarding Patient #2’s Living Will and Medical Power of Attorney, and communications regarding escalation of the Next of Kin and Medical Power or Attorney. The Administrator informed the surveyor that the hospital had provided the paperwork that consisted of the Living Will for Patient #2 to the hospice; the hospital worked that the verbiage for Successor Agent dated 6/11/2003 read that if Proxy 1 could no longer act as Patient #2’s Attorney then Signer 1 would be the Successor Attorney- which was under the Power of Attorney portion of the living will. The Surveyor discussed that health proxy listed Proxy 1 and did not list Signer 1 as a successor health proxy. The Surveyor discussed that the Health Proxy was signed in 2015, while the Power of Attorney was signed in 2003. The Administrator said, “(Signer 1) did not have medical power of attorney. “ Review of the agency’s policy titled “Patient’s Rights and Responsibilities RI. 10,” last reviewed on 10/1/2021 read in part; “Purpose To ensure the patient, their representative (if any), and the Hospice staff acknowledge, protect, observe, and implement the patient’s rights and responsibilities. Definition Representative means an individual who has the authority under State Law (whether by statute or pursuant to an appointment by the courts of the state) to authorize or terminate medical care or to elect or revoke the election of hospice care on behalf of a terminally ill patient who is mentally or physically incapacitated. This may include a legal guardian...Procedure I. The Hospice staff will be responsible for knowing, observing, and implementing the patient’s rights and patient responsibilities on an ongoing basis. The staff will also be responsible for protecting and promoting these rights...VII. If a court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient’s rights to the extent allowed by state law...” Review of the agency’s policy titled “Informed Consent Process RI.75,” last reviewed 2/1/2025, read in part; “Purpose To ensure prior to the patient receiving care, services and/or treatment related to the terminal illness or related terminal conditions, the Hospice will provide information to the patient through an informed consent process for the patient to make their own decision(s) and choice(s) about their medical care. Definition Representative means an individual who has the authority under state law (whether by statute or pursuant to an appointment by the courts of the state) to authorize or terminate medical care or to elect or revoke the election of hospice care on behalf of a terminally ill patient who is mentally or physically incapacitated. This may be a elgal guardian. Policy...III. The Hospice will follow the informed consent process incompliance with all applicable federal, state, and local laws, throughout the course of hospice care. Procedure...II. The Hospice will adhere to the following informed consent process...C. If the patient lacks decision-making capacity, the Hospice will communicate with the authorized representative, who may speak for and consent to hospice care on behalf of an adult patient who is comatose, incapacitated, or otherwise mentally or physically incapable of communication. D. The Hospice will refer to the patient’s Advance Directives, or state rules and regulations concerning surrogate hierarchy if no Advance Directive is present, to determine who is authorized to provide medical decision making when the patient is comatose, incapacitated, or otherwise mentally or physically incapable of communication...”

“Based on record review and interview, the registered nurse failed to write patient specific instructions for the hospice aide that included that patients had indwelling urinary catheters (thin hollow tube inserted into the bladder through the tract where urine empties from the bladder) for 2 (#7, #19) of 3 patient records reviewed where the patients had an indwelling urinary catheter; that the patients had a tracheostomy (permanent surgical opening made into the windpipe, where a tube would be left in place for breathing) for 2 (#3, #7) of 2 records reviewed where the patients had a tracheostomy; and that a patient had a Stage IV pressure wound (also known as a bedsore, a deep wound with exposed muscle, bone, or tendon) for 1 (#7) of 1 patient record reviewed where the patient had a wound. The failure placed the patients at risk for urinary tract, respiratory system, and wound complications. Indwelling Urinary Catheter: Based on record review and interview, the registered nurse failed to write patient specific instructions for the hospice aide that included that patients had indwelling urinary catheters (thin hollow tube inserted into the bladder through the tract where urine empties from the bladder) for 2 (#7, #19) of 3 patient records reviewed where the patients had an indwelling urinary catheter; that the patients had a tracheostomy (permanent surgical opening made into the windpipe, where a tube would be left in place for breathing) for 2 (#3, #7) of 2 records reviewed where the patients had a tracheostomy; and that a patient had a Stage IV pressure wound (also known as a bedsore, a deep wound with exposed muscle, bone, or tendon) for 1 (#7) of 1 patient record reviewed where the patient had a wound. The failure placed the patients at risk for urinary tract, respiratory system, and wound complications. Findings: Patient #19: Record review of Patient #19’s clinical record contained an initial Plan of Care dated 7/2/2024 that indicated that Patient #19 was admitted to hospice services on 7/2/2024. The Plan of Care listed Severe Protein-Calories Malnutrition (significant muscle wasting and loss of subcutaneous fat) as the terminal diagnosis. The Plan of Care contained a general assessment that Patient #19 had a Foley catheter (indwelling urinary catheter) in place and contained an order for the catheter to be changed as needed and every 30 days. Patient #19’s clinical record contained a hospice aide care plan dated 7/2/2024. The hospice aide care plan did not include that Patient #19 had an indwelling urinary catheter and did not include instructions or precautions for the indwelling urinary catheter. Tracheostomy: Patient #3: Record review of Patient #3’s clinical record revealed an Initial Plan of Care dated 1/18/2024. The Plan of Care indicated that Patient #3 was admitted to hospice services on 1/18/2024. The Plan of Care listed Secondary Pulmonary Hypertension (blood unable to flow through the blood vessels of the lungs leading to high blood pressure and heart failure) as the terminal diagnosis. Patient #3’s contained documentation of a start of care comprehensive assessment dated 1/18/2024 that was conducted by Registered Nurse D. Registered Nurse D documentation indicated that Patient #3 had a tracheostomy. Patient #3’s clinical record contained documentation of a skilled nurse visit conducted on 9/25/2024 by Registered Nurse C. Registered Nurse C documented that Patient #3 had a tracheostomy and that Registered Nurse C changed the tracheostomy tie. Patient #3’s clinical record contained a hospice aide care plan dated 1/19/2024. The hospice aide care plan did not include that Patient #3 had a tracheostomy and did not include care or precautions for the tracheostomy. Indwelling Urinary Catheter, Tracheostomy, and Wound: Patient #7:Record review of Patient #7’s clinical record revealed an Initial Plan of Care dated 12/4/2023. The Plan of Care indicated that Patient #7 was admitted to hospice services on 12/4/2023. The Plan of Care listed Non-Traumatic Intracerebral Hemorrhage in Hemisphere Cortical (bleeding in the brain without outside trauma resulting in damage and breakage of small blood vessels of the outer layer of the brain) as the terminal diagnosis. Patient #7’s clinical record contained documentation of a start of care comprehensive assessment dated 12/4/2023 that was conducted by Registered Nurse E. Registered E documented that Patient #7 had an indwelling urinary catheter, tracheostomy, and Stage IV pressure wound to the coccyx that measured 2.8 x 2.6 x 1.8 centimeters. Patient #7’s clinical record contained a hospice aide care plan dated 12/6/2023. The aide care plan did not include that Patient #7 had an indwelling urinary catheter, a tracheostomy, and wound, and did not include care or precautions for the indwelling urinary catheter, tracheostomy, and wound. On 11/12/2024 at 9:51 a.m., the surveyor reviewed the patient clinical record with the Administrator, Supervising Nurse, and the Office Manager. The surveyor discussed that the aide care plans were not patient specific and did not include when patients had an indwelling urinary catheter, tracheostomy, or wound. The Supervising Nurse informed the surveyor that the hospice aides have seen catheter, tracheostomies, and wounds. “If the hospice aide has questions, the hospice aide would call the case manager or the office.” The Supervising Nurse informed the surveyor that the Supervising Nurse would review and follow up regarding aide care plans. During an interview on 11/13/2024 at 8:50 a.m. with Registered Nurse F, the surveyor discussed aide care plans. The surveyor asked if a patient had a Foley catheter, would that be something to be included in the aide care plan. Registered Nurse F informed the surveyor that the aide care plan would need to include catheter care. During an interview on 11/13/2024 at 10:10 a.m. with Registered Nurse G, the surveyor discussed aide care plans. The surveyor asked if a patient had a Foley catheter, a tracheostomy, or wound, would that be something to be included in the aide care plan. Registered Nurse G informed the surveyor that the Foley catheter, tracheostomy, and wound should be included in the aide care plan. During an interview on 11/13/2024 at 11:50 a.m. with Registered Nurse H, the surveyor discussed aide care plans. The surveyor asked if a patient had a Foley catheter, tracheostomy, or wound, would that be something to be included in the aide care plan. Registered Nurse H stated, “Yes.” During an interview on 11/14/2024 at 12:03 p.m. with the Supervising Nurse, Registered Nurse I (phone), and Registered Nurse J (phone), the surveyor discussed the follow up to the aide care plans. The Registered Nurse I informed the surveyor that catheter care, tracheostomies, and wounds should be included in the aide care plan. Registered Nurse I was going to review records and get back with the surveyor regarding findings. The surveyor asked how often were the aide tasks reviewed. Registered Nurse I informed the surveyor that the tasks were discussed in the interdisciplinary team meetings and updated if there was a change. Registered Nurse I informed the surveyor that updating the aide care plan was the responsibility of the case manager. During an interview on 11/14/2024 at approximately 3:49 p.m. with the Supervising Nurse and Registered Nurse I, Registered Nurse I informed the surveyor that Patient #3 had a respiratory care plan. The surveyor asked if the tracheostomy was included in the respiratory care plan. Registered Nurse I stated, “The tracheostomy was not included in the respiratory care plan. The surveyor asked how the patients could be affected. Registered Nurse I stated, “It could cause confusion in care.” The surveyor asked if there were any disputes to the finding. The Supervising Nurse and Registered Nurse I stated, “No.” Review of the agency’s policy titled “Implementing Care and Treatment,” labeled PC.35. and last reviewed on 9/1/2024. The policy read in part: “Purpose To ensure patient care and treatment are provided as identified in the care planning process. Policy I. The Hospice staff providing patient care and treatment will be competent to the level of care/treatment needed...Procedure...III. The Hospice RN, who is a member of the IDG/IDT, will oversee the assignment of a Hospice Aide (HA) to a particular patient, initiating hospice aide services within time frame to meet identified patient’s needs as identified in the POC and per physician orders. IV. The HA will be provided with written instructions for patient care prepared by an RN which may include but not be limited to...Personal care...””

“Based on record review and interview, the hospice failed to have physician orders in the patient records for changes in hospice aide visit frequencies for 8 (#2, #3, #8, #11, #12, #13, #17, #18) of 14 active patient records reviewed. The failure placed the patients at risk for omission or inappropriate care that could result in a negative affect to their health status. Patient #2: Record review of Patient #2’s clinical record revealed an Initial Plan of Care dated 4/30/2024. The Plan of Care indicated that Patient #2 was admitted to the agency’s services on 4/30/2024. The Plan of Care listed Cirrhosis of the Liver (scarred and permanently damaged Liver) as the terminal diagnosis. Patient #2’s clinical record contained a physician order dated 8/21/2024 that increased the hospice aide visit frequency from 3 times a week to 5 times a week to start the week of 8/26/2024. Patient #2 received 4 hospice aide visits the week of 9/8/2024 and 9/15/2024. Patient #2’s record did not contain a physician order to decrease the hospice aide visit frequency from 5 times each week to 4 time a week for the weeks of 9/8/2024 and 9/15/2024. Patient #3: Record review of Patient #3’s clinical record revealed an Initial Plan of Care dated 1/18/2024. The Plan of Care indicated that Patient #3 was admitted to hospice services on 1/18/2024. The Plan of Care listed Secondary Pulmonary Hypertension (blood unable to flow through the blood vessels of the lungs leading to high blood pressure and heart failure) as the terminal diagnosis. Patient #3’s record contained an order dated 7/4/2024 that clarified that Patient #3 was to received hospice aide visits 5 times each week. Patient #3 received 4 hospice aide visits the week of 9/22/2024. Patient #3’s record did not contain a physician order to decrease the hospice aide visit frequency from 5 times each week to 4 time a week for the week of 9/22/2024. Patient #8: Record review of Patient #8’s clinical record revealed an Initial Plan of Care dated 1/31/2024. The Plan of Care indicated that Patient #8 started on hospice service on 1/31/2024. The Plan of Care listed Chronic Obstructive Pulmonary Disease (progressive disease damaging the lungs, making it hard to breathe) as the terminal diagnosis. The Plan of Care contained an order for the hospice aide to visit 5 times each week. Patient #8 received 3 hospice aide visits the weeks of 7/28/2024, 8/4/2024, and 8/11/2024 (one missed visit). Patient #8 did not receive hospice aide visits the week of 8/18/2024. Patient #8 received 1 hospice aide visit the weeks of 8/25/2024, 9/1/2024 (missed visit), 9/8/2024 (missed visit), 9/15/2024, and 9/22/2024. Patient #8’s clinical record did not contain physician orders to decrease the hospice aide visit frequency from 5 times each week to 3 times each week or to 1 time each week. Patient #11: Record review of Patient #11’s clinical record contained an Initial Plan of Care dated 4/13/2023. The Plan of Care indicated that Patient #11 was admitted to hospice service on 4/13/2023. The Plan of Care listed Chronic Obstructive Pulmonary Disease (progressive disease damaging the lungs, making it hard to breathe) as the terminal diagnosis. The Plan of Care contained an order for Patient #11 to received hospice aide visits 2 times each week. Patient #11 received 1 hospice aide visit the week of 8/11/2024. Patient #11 received 5 hospice aide visits the week of 9/15/2024. Patient #11’s clinical record did not contain a physician order to change the hospice aide visit frequency to 1 time a week or to 5 times a week. Patient #12: Record review of Patient #12’s clinical record revealed an Initial Plan of Care dated 8/15/2024. The Plan of Care indicated that Patient #12 was admitted to hospice services on 8/15/2024. The Plan of Care listed Parkinson’s (progressive disorder of the nervous system causing nerve cell death in the brain) as the terminal diagnosis. The Plan of Care contained an order for the hospice aide to visit 5 times each week. Patient #12’s clinical record contained a physician order dated 8/15/2024, for Patient #12 to receive hospice aide visits 4 times each week. Patient #12 received 3 hospice aide visits the weeks of 8/25/2024, 9/8/2024 (with 2 missed visits), and 9/29/2024 (1 missed visit). Patient #12 received 1 hospice aide visit the week of 10/6/2024 (with 1 missed visit). Patient #12’s clinical record did not contain orders to change the hospice aide visit frequency from 4 times each week to 3 times a week or to 1 time a week. Patient #13: Record review of Patient #13’s clinical record revealed an Initial Plan of Care dated 5/17/2024. The Plan of Care indicated that Patient #13 was admitted to hospice services on 5/17/2024. The Plan of Care listed Unspecified Severe Protein-Calorie Malnutrition (significant muscle wastingand loss of subcutaneous fat) as the terminal diagnosis. The Plan of Care contained an order for Patient #13 to received hospice aide visits 5 times each week. Patient #13’s record contained a physician order dated 9/9/2024 for Patient #13 to receive hospice aide visits 5 times each week. Patient #13 received 3 hospice aide visits the week of 9/1/2024. Patient #13’s clinical record did not contain a physician order to decrease the aide visit frequency from 5 times each week to 3 times a week. Patient #17: Record review of Patient #17’s clinical record revealed an Initial Plan of Care dated 5/15/2023. The Plan of Care indicated that Patient #17 was admitted to hospice services on 5/15/2023. The Plan of Care listed Alzheimer’s with Late Onset (loss of thinking, remembering, and reasoning occurring after age 65) the terminal diagnosis. Patient #17’s record contained a physician order dated 10/4/2023 for hospice aide visits 5 times each week. Patient #17 received 3 hospice aide visits the week of 10/27/2024. Patient #17’s record did not contain an order to decrease hospice aide visit frequency from 5 times a week to 3 times a week. Patient #18: Record review of Patient #18’s clinical record revealed an Initial Plan of Care dated 7/10/2024. The Plan of Care indicated that Patient #18 was admitted to hospice service on 7/10/2024. The Plan of Care listed Malignant Neoplasm of the breast (cancer) as the terminal diagnosis. The Plan of Care contained an order for hospice aide visits 5 times each week. Patient #18 received 3 hospice aide visits the weeks of 8/18/2024, 8/25/2024, 9/1/20204, and 9/8/2024. Patient #18’s record did not contain a physician order to change the hospice aide visit frequency from 5 times each week to 3 times a week. During an interview on 11/12/2024 at 9:51 a.m. with the Administrator, Supervising Nurse, and the Office Manager, the surveyor discussed that hospice aide visit frequencies and that the patient records did not have physician orders for the changes in the hospice aide frequencies. The Supervising Nurse informed the surveyor that physician orders should be written when there was an aide frequency change. The Supervising Nurse informed the surveyor that aide frequencies were discussed at the interdisciplinary team meetings. During an interview on 11/13/2024 at 10:10 a.m. with Registered Nurse G, the surveyor asked the what was the process when a change in aide frequency occurred. Registered Nurse G informed the surveyor that Registered Nurse G would call, email, or text the aide. Registered Nurse G informed the surveyor that an order would be written and the changed on the calendar (computer). Registered Nurse G informed the surveyor that the nurses would make adjustments on the calendar for frequency change. Registered Nurse G stated,” a physician order should be written right away, same day, or before the end of the shift.” During an interview on 11/13/2024 at 11:50 a.m. with Registered Nurse H, the surveyor asked what was the process when a change in aide visit frequency occurred. Registered Nurse H informed the surveyor that there would be a physician order and the nurse would adjust the aide schedule. During an interview on 11/14/2024 at 12:03 p.m. with the Supervising Nurse, Registered Nurse I, and Registered Nurse J, the surveyor discussed that the patient records did not contain physician orders for the changes in the hospice aide frequencies. The surveyor asked who was responsible for ensuring the physician orders would be in the patient records. Registered Nurse I stated, “The case manager.” The surveyor was informed that it seemed to be hit or miss with orders written for aide frequency change. During an interview on 11/14/2024 at 3:39 p.m. with the Supervising Nurse and Registered Nurse I, Registered Nurse I informed the surveyor that orders for aide frequency changes were place in there (the patient records). The surveyor asked were there any disputes regarding the finding. The Supervising Nurse and Registered Nurse I stated, “No.” The surveyor asked how it might affect the agency’s patients. Registered Nurse I stated, “It could cause confusion in care.” Review of the agency’s policy titled “Timelines,” labeled IM.40, and reviewed on 9/1/2024 read in part; “Purpose To establish timely parameters for medical record information. Policy...II. The Hospice will establish staff responsibilities for acceptable timeframes for completion and submission of medical record information, including, but not limited to: visit notes and assessments, physician orders...Procedure...III. All medical record information will be incorporated into the patient’s medical record in a timely manner...””

“Based on observation, record review and interview, the hospice failed to include in the written agreement with the skilled nursing facilities, the delineation of the hospice’s responsibilities that included, but not limited to: medical direction and management, nursing, counseling, social work, provision of medical supplies, durable medical equipment, drugs and all other services necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions for 2 (#4 and #17) of 2 patients that resided in a skilled nursing facility where a home visit was conducted. The failure placed the patients at risk of omission of care or delayed care due to confusion of the hospice’s responsibilities, which could result in poor symptom control. During an interview on 11/12/2024 at 9:51 a.m. with the Administrator, Supervising Nurse, and the Office Manager, the surveyor reviewed the clinical records. The surveyor discussed that the clinical record did not contain a delineation of the hospice responsibilities for Patient #4. The Supervising Nurse would follow up. Patient #4: Record review of Patient #4’s clinical record revealed an Initial Plan of Care dated 12/30/2022. The Plan of Care indicated that Patient #4 started on the Hospice’s services on 12/30/2022. The Initial Plan of Care listed Alzheimer’ Late Onset (brain disease causing loss of intellectual functions with impaired memory and thinking that developed after the age of 65) as the terminal diagnosis. The Interdisciplinary Team meeting documentation dated 10/29/24 indicated that Patient #4 lived at an assisted living facility on the memory care unit but moved to a skilled nursing facility in October 2024. A home visit was conducted on 11/13/2024 at 9:45 a.m. at Facility X, a skilled nursing facility. The surveyor reviewed the hospice record that was at Facility X. The record did not contain a delineation of the hospice’s responsibility. During an interview at Facility X at 10:10 am. with Registered Nurse G, a hospice nurse, the surveyor discussed the delineation. Registered Nurse G informed the surveyor that a delineation had been done. Registered Nurse G did not know why the delineation was not in the hospice record at the facility. During an interview on 11/13/2024 at 10:23 a.m. with Facility X Director of Nursing, the surveyor asked where the surveyor could find the delineation of hospice responsibilities. Facility X Director of Nursing informed the survey that the delineation would be in the hospice record at the facility. Patient #17: Record review of Patient #17’s clinical record revealed an Initial Plan of Care dated 5/15/2023. The Plan of Care indicated that Patient #17 started on the agency’s services on 5/15/2023. The Initial Plan of Care listed Alzheimer’s Disease Late Onset as the terminal diagnosis. The Interdisciplinary Team meeting documentation dated 11/5/2024 indicated that Patient #17 lived at Facility Y, a skilled nursing facility. A home visit was conducted on 11/13/2024 at 11:30 a.m. at Facility Y, a skilled nursing facility. The surveyor reviewed the hospice record that was at Facility Y. The record did not contain a delineation of the hospice’s responsibility. The surveyor asked Registered Nurse H, a hospice nurse, about the delineation. Registered Nurse H reviewed the hospice record at the facility. Registered Nurse H stated, “I’m not seeing it.” The surveyor asked who would be responsible for the delineation. Registered Nurse H stated, “The admit nurse should have done it.” The surveyor asked if Registered Nurse H had done the admission for Patient #17. Registered Nurse H stated, “No.” Registered Nurse H did not know why the delineation was not in the hospice record at the facility. During an interview on 11/14/2024 at 12:03 p.m. with the Supervising Nurse, the surveyor discussed the home visits regarding Patient #4 and Patient #17. The surveyor discussed that the skilled nursing facilities did not have a delineation of the hospice responsibilities. The surveyor asked who was responsible for the delineation. The Supervising Nurse stated, “The case managers. The admit nurse would do the delineation and the case manager would follow up to make sure the documentation was there.” The Supervising Nurse stated, “[Patient #4] just moved there (to the skilled nursing facility) and [Patient #17], the nurse was new.” During an interview on 11/14/2024 at 5:46 p.m. with the Administrator and Supervising Nurse, the surveyor asked if the agency had any questions or disputes regarding the finding. The Administrator and Supervising Nurse stated, “No.” Review of the agency’s policy titled “Hospice Care in a SNF/NF or ICF/IID,” labeled PC.125, and last reviewed on 9/1/2024, read in part; “Purpose To describe the process for providing hospice care to resident of a Skilled Nursing Facility/Nursing Facility (SNF/NF) or Intermediate Care Facility or Intermediate Facility for the Intellectually and Development Disabled (ICF/IID). Policy I. The Hospice and the facility will have a legally written binding contract/agreement in place defining the provision of services to hospice patients in a SNF/NF or ICF/IID prior to the provision of hospice services...Procedure...II. The Hospice responsibilities will include, but not limited to, providing the following: A. Medical direction and management of the patient; B. Nursing; C. Counseling, including spiritual, dietary and bereavement; D. Social Work (may also be provided by Mental Health Counselor and/or Marriage and Family Therapist); E. Medical supplies, durable medical equipment and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; F. Other hospice services that are necessary for the care of the residents’ terminal illness and related conditions...””