Principle Hospice Service LLC

“Based on record review and interview, the agency failed to include in the plan of care, all services necessary services for the palliation and management of the terminal illness and related condition including drugs and treatment necessary to meet the need of the patient, in that wound care treatment was not included in the plan of care for 1 (Patient #11) of 3 patient records reviewed where the patient received wound care. The failure placed the patient at risk of wound infection or worsening of wounds. Patient #11: Record review of Patient #11’s clinical record revealed a Plan of Care Dated 4/4/2025 to 6/2/2025. The Plan of Care listed Transient Cerebral Ischemic Attack and related syndromes (brief blockage of blood flow to the brain with symptoms that mimic a major stroke—sudden numbness, slurred speech, or vision loss) as the terminal diagnosis. The Plan of Care did not contain orders for wound care. Registered Nurse D conducted an initial comprehensive assessment on 4/4/2025. Registered Nurse D documented that Patient #11 had wound to the sacral coccyx (lower back) that measured 3 x 3 x 1 centimeters. Registered Nurse D documented wound care, per Physician X, cleaned with normal saline (fluid matching the body’s natural salt and water balance used to clean wounds), patted dry, apply betadine (used to disinfect minor cuts, scrapes, and burns, and prevent infections) to wound and cover with border foam dressing (sterile, multi-layered wound care product featuring a soft, highly absorbent central foam pad and surrounding adhesive border). Registered Nurse D documented that Patient #11 had a wound to the left heel that measured 2 x 3 centimeters. Registered Nurse D documented cleaning the left heel wound, per Physician X, with normal saline, patted dry, apply betadine, and covered with bordered foam dressing. Licensed Vocational Nurse E conducted a skilled nurse visit on 4/15/2025. Licensed Vocational Nurse E documented that wound care was performed as physician ordered. Licensed Vocational Nurse E conducted a skilled nurse visit on 4/22/2025. Licensed Vocational Nurse E documented that wound care was performed as physician ordered. Patient #11 died on 4/30/2025. Patient #11’s clinical record contained Plans of Care dated 4/11/2025, and 4/25/2025. The Plans of Care contained an order that the registered nurse would perform wound care as ordered by the physician. Patient #11’s Plan of Care did not include the wound care treatment to be provided for Patient #11. Registered Nurse D was no longer employed at the agency. During an interview on 6/25/2026 at 1:51 PM with the Alternate Administrator/Supervising Nurse, the Surveyor discussed that nursing staff were performing wound care treatments to Patient #11 and Patient #11’s Plan of Care did not include wound care treatments. The Surveyor asked who would be responsible to ensure that the Plan of Care included wound care. The Alternate Administrator/Supervising Nurse said, “It would be the Registered Nurse that was seeing the patient.” The Surveyor discussed that Patient #11 received a visit by a Registered Nurse for the admit visit and for the discharge visit. The Surveyor asked who would be responsible to ensure the Plan of Care included wound care treatment if the licensed vocational nurse was seeing the patient. The Alternate Administrator/Supervising Nurse informed the Surveyor that the nurse would call the physician to get orders. The Alternate Administrator/Supervising Nurse stated, “It was an error that it was not on the Plan of Care.” During an interview on 6/26/2026 at 1:43 PM with Licensed Vocational Nurse E. the Surveyor discussed the wound care performed for Patient #11. The Surveyor asked Licensed Vocational Nurse E how would Licensed Vocational Nurse E would know what the wound care would be for a patient. Licensed Vocational Nurse E stated, “By a physician’s order or if they had been at the hospital.” The Surveyor asked what if there were no order for wound care in the chart. Licensed Vocational Nurse E informed the Surveyor that it would be communicated to Licensed Vocational Nurse E. The Surveyor asked if the admitting nurse would communicate to Licensed Vocational Nurse E. Licensed Vocational Nurse E stated, “Yes.” The Surveyor asked if Licensed Vocational Nurse remembered what the wound care for Patient #11 had been. Licensed Vocational Nurse E did not remember the wound care. Licensed Vocational Nurse E called the Surveyor on 6/26/2026 at 2:56 PM. Licensed Vocational Nurse E informed the surveyor that the wound care order was in the Initial Comprehensive Assessment done by Registered Nurse D. Licensed Vocational Nurse E had informed the Surveyor that Registered Nurse D was not communicative with Licensed Vocational Nurse E. The Surveyor asked if the nursing note was the Plan of Care. Licensed Vocational Nurse E stated, “No.” Review of the agency’s policy titled “Plan of Care Process PC.30,” last reviewed on 3/16/2026 read in part; “Purpose To ensure that the care provided is in accordance with the written Plan of Care (POC), appropriately planned, and delivered in a timely manner to meet the patient’s and family’ specific needs. Policy I. All hospice care and services furnished to patients and their families will follow an individualized written POC established by the Hospice Interdisciplinary Group/Team (IDG/IDT) in collaboration with the Attending Physician (if any), the patient or representative, and the primary caregiver, if any of them so desire, and in accordance with the patient’s needs...Procedure...VI. The POC includes, but is not limited to...D. Drugs and treatments necessary to meet the needs of the patient...””

“Based on record review and interview, the interdisciplinary group- core group of a physician, registered nurse, chaplain, and social worker that provided/supervised all care and services, ensuring a holistic approach to terminal illness and bereavement, (in collaboration with the individual’s attending physician, if any) failed to review, revise and document the patient’s individualized plan of care as frequently as the patient’s condition required but no less frequently than every 15 days, in that the interdisciplinary group failed to revise the plan of care regarding wound care for 2 (Patient #5, Patient #11) of 3 records reviewed where the patient received wound care, and/or failed to revise frequency of visits for 6 (Patient #5, Patient #6, Patient #9, Patient #11, Patient #12, Patient #13) of 14 patient records reviewed. The failure placed patients at risk of wounds becoming infected or worsening, and spiritual or psychosocial needs not being identified or going unmet. WOUNDS Patient #5:Patient #5’s clinical record contained a Plan of Care dated 3/27/2026. The Plan of Care listed Atherosclerotic Heart Disease of Native Coronary Artery with unspecified Angina Pectoris (natural arteries supplying blood to the heart are narrowed and hardened by fatty plaque buildup causing chest pain) as the terminal diagnosis. The Plan of Care contained an order for wound care to Patient #5’s right ankle wound to be cleaned with warm soapy water, apply Silvadene (prescription-strength topical cream used to prevent and treat infections in severe second- and third-degree burns) twice a day, and leave open to air. Record review of Patient #5’s clinical record revealed an Initial Comprehensive assessment that indicated that Patient #5 started on the hospice’s services on 2/7/2026. Registered Nurse C conducted a recertification comprehensive assessment on 3/28/2026. Registered Nurse C documented that the wound to Patient #5’s right ankle wound was closed. Patient #5 was discharged on 6/2/2026. Patient #5’s clinical record contained Plans of Care dated 4/10/2026, 4/24/2026, 5/8/2026, and 5/22/2026. The Plans of Care contained the order to clean the right ankle wound with warm soapy water, apply Silvadene twice a day and leave open to air. The interdisciplinary group met on 4/10/2026, 4/24/2026, 5/8/2026, and 5/22/2026. The interdisciplinary group failed to revise the Plans of Care to remove the wound care to Patient #5’s right ankle. Patient #11: Record review of Patient #11’s clinical record revealed a Plan of Care Dated 4/4/2025 to 6/2/2025. The Plan of Care listed Transient Cerebral Ischemic Attack and related syndromes (brief blockage of blood flow to the brain with symptoms that mimic a major stroke—sudden numbness, slurred speech, or vision loss) as the terminal diagnosis. The Plan of Care did not contain orders for wound care. Registered Nurse D conducted an initial comprehensive assessment on 4/4/2025. Registered Nurse D documented that Patient #11 had wound to the sacral coccyx (lower back) that measured 3 x 3 x 1 centimeters. Registered Nurse D documented wound care, per Physician X, cleaned with normal saline (fluid matching the body’s natural salt and water balance used to clean wounds), patted dry, apply betadine (used to disinfect minor cuts, scrapes, and burns, and prevent infections) to wound and cover with border foam dressing (sterile, multi-layered wound care product featuring a soft, highly absorbent central foam pad and surrounding adhesive border). Registered Nurse D documented that Patient #11 had a wound to the left heel that measured 2 x 3 centimeters. Registered Nurse D documented cleaning the left heel wound, per physician X, with normal saline, patted dry, apply betadine, and covered with bordered foam dressing. Licensed Vocational Nurse E conducted a skilled nurse visit on 4/15/2025. Licensed Vocational Nurse E documented that wound care was performed as physician ordered. Licensed Vocational Nurse E conducted a skilled nurse visit on 4/22/2025. Licensed Vocational Nurse E documented that wound care was performed as physician ordered. Patient #11 died on 4/30/2025. Patient #11’s clinical record contained Plans of Care dated 4/11/2025, and 4/25/2025. The Plans of Care contained an order that the registered nurse would perform wound care as ordered by the physician. The interdisciplinary group met on 4/11/2025 and 4/25/2025. The interdisciplinary group failed to revise the Plans of Care to include the specific physician ordered wound care to Patient #11’s wounds. VISIT FREQUENCY Patient #5:Patient #5’s clinical record contained a Plan of Care dated 4/7/2026 to 6/2/2026. The Plan of Care listed Atherosclerotic Heart Disease of Native Coronary Artery with unspecified Angina Pectoris as the terminal diagnosis. The Plan of Care contained orders for Chaplain visits once a month for 3 months and Social Work visits once a month for 2 months. Record review of Patient #5’s clinical record revealed an Initial Comprehensive assessment that indicated that Patient #5 started on the hospice’s services on 2/7/2026. Patient #5 last Chaplain visit was on 3/11/2026. Patient #5 did not receive a Chaplain visit in April 2025, or May 2025. Patient #5 did not receive a visit from a Social Worker while on the hospice’s services. The Plans of Care dated 3/27/2026, 4/10/2026, 4/24/2026, 5/8/2026, and 5/22/2026 contained orders for Patient #5 to receive Chaplain visits once a month for 3 months and Social Work visits once a month for 2 months. The interdisciplinary group met on 3/28/2026, 4/10/2026, 4/24/2026, 5/8/2026, and 5/22/2026. The interdisciplinary group failed to revise the Plans of Care for the frequency of Chaplain and Social Work visits. Patient #6:Record review of Patient #6’s clinical record revealed a Plan of Care dated 3/27/2026. The Plan of Care listed Senile Degeneration of the Brain (decline in memory and reasoning) as the terminal diagnosis. The Plan of Care contained an order for Patient #6 to receive a Chaplain visit once a month for 3 months. Patient #6’s clinical record contained consents with the election date for service of 1/31/2026. Patient #6’s last Chaplain visit was on 3/19/2026. Patient #6 did not receive a Chaplain visit in April 2026. Patient #6 was discharged 5/26/2026. Patient #6’s clinical record contained Plans of Care dated 4/10/2026, 4/17/2026, 4/24/2026, 5/8/2026, and 5/22/2026. The Plans of Care contained an order for Patient #6 to receive a Chaplain visit once a month for 3 months. The interdisciplinary group met on 4/10/26, 4/17/2026, 4/24/2026, 5/8/2026, and 5/22/2026. The Interdisciplinary group failed to revise the Plans of Care for the frequency of Chaplain visits. Patient #9:Record review of Patient #9’s clinical record contained a Plan of Care dated 3/27/2026. The Plan of Care listed Alzheimer’s Disease (progressive, irreversible brain disorder that destroys memory, thinking skills, and the ability to carry out simple daily tasks) as the terminal diagnosis. The Plan of Care contained orders for Patient #9 to receive Chaplain visits once a week and Social Work visits once a month. Patient #9’s record contained consents that indicated the election date for hospice services was 1/31/2026. Patient #9’s clinical record contain Chaplain visits conducted on 2/13/2026 and 3/25/2026. Patient #9 did not receive Chaplain visits weekly. Patient #9’s clinical record indicated that Patient #9 had not received a Social Work visit while on service. Patient #9 was discharged on 5/30/2026. Patient #9’s clinical record contained Plans of Care dated 4/10/2026, 4/24/2026, 5/8/2026, and 5/22/2026. The Plans of Care contained an order for Patient #9 to receive a Chaplain visit once a week and Social Work visits once a month. The interdisciplinary group met on 4/10/26, 4/24/2026, 5/8/2026, and 5/22/2026. The Interdisciplinary group failed to revise the Plan of Care for the frequency of Chaplain visits and the frequency of Social Work visits. Patient #11:Record review of Patient #11’s clinical record revealed a Plan of Care Dated 4/4/2025 to 6/2/2025. The Plan of Care listed Transient Cerebral Ischemic Attack and related syndromes (brief blockage of blood flow to the brain with symptoms that mimic a major stroke—sudden numbness, slurred speech, or vision loss) as the terminal diagnosis. The Plan of Care contained an order for Patient #11 to receive Chaplain and Social Work visits once a week. Patient #11’s clinical record contained documentation of a Social Work visits by Social Worker G on 4/8/2025. Patient #11’s clinical record did not indicate that Patient #11 received a Social Work visit weekly. Patient #11’s clinical record did not indicate that Patient #11 received a Chaplain visit while on services. Patient #11 died on 4/30/2025. Patient #11’s clinical record contained Plans of Care dated 4/11/2025 and 4/25/2025. The Plans of Care contained orders for Patient #11 to receive Chaplain and Social Work visits once a week. The interdisciplinary group met on 4/11/25 and 4/25/2025. The Interdisciplinary group failed to revise the Plans of Care for the frequency of Chaplain visits and the frequency of Social Work visits. Patient #12: Record review of Patient #12’s clinical record revealed a Plan of Care dated 8/13/2025. The Plan of Care listed Other Alzheimer’s Disease (brain disorder characterized by the buildup of abnormal proteins that destroy memory and thinking) as the terminal diagnosis. The Plan of Care contained an order for Patient #12 to received Aide visits 5 times each week. Review of Patient #12’s clinical record revealed that 10/1/2025 was the last day that Patient #12 received an Aide visit. Patient #12 died 10/14/2025. Patient #12’s clinical record contained a Plans of Care dated 9/26/2025, 10/9/2025, and 10/12/2025. The Plans of Care contained an order for Patient #12 to receive Aide visits 5 times each week. The interdisciplinary group met on 9/26/2025 and 10/9/2025. The interdisciplinary group failed to revise the Plans of Care for the change in frequency of Aide visits. Patient #13:Record review of Patient #13’s clinical record revealed a Plan of Care dated 2/14/2025. The Plan of Care Listed Senile Degeneration of the Brain (decline in memory and reasoning) as the terminal diagnosis. The Plan of Care contained an order for Patient #13 to receive Chaplain visits once a month. Chaplain F conducted a Chaplain visit on 4/2/2025. The visit on 4/2/2026 was the only visit conducted by a chaplain since Patient #13 was admitted to services. Patient #13’s record did not indicate that Patient #13 received a chaplain visit in February 2025 or March 2025. Patient #13 died on 4/8/2025. Patient #13’s clinical record contained Plans of Care dated 2/28/25, 3/14/25, and 3/27/2025. The Plans of Care contained an order for Patient #13 to receive Chaplain visits once a month. The Interdisciplinary group met on 2/14/2025, 2/28/2025, 3/14/2025, and 3/28/2025. The Interdisciplinary group failed to revise the Plans of Care for Chaplain frequency. During an interview on 6/25/2026 at 1:51 PM with the Alternate Administrator/Supervising Nurse, the Surveyor discussed the Plans of Care not being revised regarding wound care and frequency of visits by staff. The Surveyor asked who was responsible to revise the Plans of Care. The Alternate Administrator/Supervising Nurse stated that the registered nurse case manager would be responsible but that ultimately it would be the Alternate Administrator/Supervising Nurse. The Surveyor asked how the agency conducted interdisciplinary group meetings. The Alternate Administrator/Supervising Nurse informed the Surveyor that it was done at the physician’s home and others would be on zoom. The Plan of Care would be visualized by projector. The Alternate Administrator/Supervising Nurse would look into the staff frequencies. The Alternate Administrator/Supervising Nurse did not know why the Plans of Care had not been revised. The Alternate Administrator/Supervising Nurse had informed the Surveyor that there had been clinical issues at one of the Alternate Delivery Sites and that they had transferred their patients to other hospices at that Alternate Delivery Site. The Alternate Administrator/Supervising Nurse informed the Surveyor that Registered Nurse C, Registered Nurse D, and Chaplain F no longer worked at the agency. During an interview on 6/26/2026 at 1:43 PM with Licensed Vocational Nurse E. the Surveyor discussed the wound care performed for Patient #11. The Surveyor asked Licensed Vocational Nurse E how would Licensed Vocational Nurse E would know what the wound care would be for a patient. Licensed Vocational Nurse E stated, “By a physician’s order or if they had been at the hospital.” The Surveyor asked what if there were no order for wound care in the chart. Licensed Vocational Nurse E informed the Surveyor that it would be communicated to Licensed Vocational Nurse E. The Surveyor asked if the admitting nurse would communicate to Licensed Vocational Nurse E. Licensed Vocational Nurse E stated, “Yes.” The Surveyor asked if Licensed Vocational Nurse remembered what the wound care for Patient #11 had been. Licensed Vocational Nurse E did not remember the wound care. Licensed Vocational Nurse E call the Surveyor on 6/26/2026 at 2:56 PM. Licensed Vocational Nurse E informed the surveyor that the wound care order was in the Initial Comprehensive Assessment done by Registered Nurse D. Licensed Vocational Nurse E had informed the Surveyor that Registered Nurse D was not communicative with Licensed Vocational Nurse E. The Surveyor asked if the nursing note was a physician order. Licensed Vocational Nurse E stated, “No.” Review of the agency’s policy titled “Plan of Care Process PC.30,” last reviewed 3/16/2026, read in part; “Purpose To ensure that the care provided is in accordance with the written Plan of Care (POC), appropriately planned, and delivered in a timely manner to meet the patient’s and family’s specific needs. Policy I. All hospice care and services furnished to patients and their families will follow an individualized written POC, established by the Hospice Interdisciplinary Group/Team (IDG/IDT) in collaboration with the Attending Physician (if any), the patient or representative, and the primary caregiver, if any of them so desire, and in accordance with the patient’s needs. II. The Hospice will develop an individualized written POC for each patient. The POC must reflect patient and family goals and interventions based on the problems identified in the initial comprehensive, and updated comprehensive assessments. The POC will include all services necessary for the palliation and management of the terminal illness and related conditions...Procedure...VI. The POC includes, but is not limited to...B. A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs...VII. The Hospice IDG/IDT, in collaboration with the individual’s attending physician, if any, will review, revise, and document the individualized plan as frequently as the patient’s condition requires, but no less frequently that every 15 calendar days...””