Omega Hospice Care, LLC

“Based on record review and interview, the agency failed to protect the patient’s right to a confidential clinical record for 1 (Patient #4) of 4 active patient records reviewed. The failure placed the patients at risk of losing trust in the providers providing care. Patient #4:Record review of Patient #4’s clinical record revealed a Plan of Care dated 2/24/3036 to 4/24/2026. The Plan of Care indicated that Patient #4 was admitted to the agency’s services on 2/24/2026. The Plan of Care listed Atherosclerotic Heart Disease of Native Coronary artery (reduced blood flow to the heart muscle due to buildup of fats, cholesterol and other substances in and on the walls of the heart arteries) without Angina Pectoris (chest pain) as the terminal diagnosis. The Plan of Care did not list Patient #4’s medications. The surveyor received a phone call on 4/14/2026 from a Confidential Witness that a photo of Patient #4’s medications and a medication list had been texted to a non-employee of the agency. The surveyor received an email on 4/14/2026 with a photo of medication bottles and a medication list for Patient #4. The photo showed the following medication bottles- Tylenol Rapid Relief 500 mg tablets- used to treat pain/fever, Sleep Quick- Melatonin 10 milligrams - used to regulate sleep, Divalproex 250 milligrams- used to treat seizures (abnormal electrical activity in the brain temporarily affecting consciousness, muscle control and behavior) and migraine (intense throbbing pain of the head lasting from hours to days) headaches, Clonidine (used to treat high blood pressure- the condition of the force of the blood against artery- blood vessel, walls being consistently too high) 0.1milligrams, Trazodone (used to treat major depressive disorder- persistent sadness, loss of interest or pleasure, and impaired daily functioning) 50 milligrams, Pantoprazole (used to reduce acid production in the stomach), Levothyroxine (used to treat condition where the thyroid gland does not produce enough thyroid hormone), another bottle with Melatonin 10 milligrams, and Cyclobenzap- the rest of the medication name was not visible, and a cough and congestion medication- name of medication not readable. The photo included a document of a list of medications with the name of Facility X on it. The document listed the following medications: Divalproex, Trazodone, Pantoprazole, Clonidine, Melatonin, and Levothyroxine. The document and seven medication bottles showed the name of Patient #4. The surveyor called the phone number that was indicated on the text message on 4/15/26 at 1:23 PM. The phone was answered by Registered Nurse D. Registered Nurse D confirmed that Registered Nurse D was employed at the agency. The surveyor asked Registered Nurse D if Registered Nurse D had texted a photo of medication bottles and a document with a list medications of Patient #4 to the wrong phone number yesterday (4/14/2024). Registered Nurse D stated, “Yes, I did.” The surveyor asked what the policy regarding texting private health information to was. Registered Nurse D informed the surveyor that Registered Nurse D was not sure of the policy regarding texting of patient information. The surveyor asked why Registered Nurse D had texted the photos of Patient #4’s medications. Registered Nurse D informed the surveyor that a caregiver (not named by Registered Nurse D) at a facility wanted the medications and gave Registered Nurse D the wrong phone number. During an interview on 4/15/2026 at approximately 4:15 PM with the Administrator/Supervising Nurse and Chief Financial Officer, the surveyor asked what measures the agency used to keep patient records confident. The Administrator/Supervising Nurse stated, “The records are locked in the office; use of electronic medical records; make sure not to use patient full name in a business app that the agency utilized that was encrypted and secured, can send wound pictures; and we use an electronic prescription with the physicians. The surveyor asked if Patient #4 took medications. The Administrator/Supervising Nurse stated, “(Patient #4) takes medications.” The surveyor asked if the Administrator/Supervising Nurse had known that a photo was texted to a non-employee that revealed medication bottles and a document with a list of medications for Patient #4. The Administrator/Supervising Nurse stated, “No, not until (Registered Nurse C) called after speaking to you. The Administrator/Supervising Nurse did not know why Registered Nurse C had texted the picture. Review of the agency’s policy titled “Patient’s Right and Responsibilities RI.10,” last reviewed on 10/1/2022, 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. Policy...II. The Hospice staff will receive in-service education regarding patient’s rights and responsibilities on hire and annually thereafter...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...IX. Regarding patient’s rights, the patient has a right to the following...E. To have a confidential clinical record...””

“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 drugs were not included in the plans of care for 2 (Patient #2 and Patient #4) of 4 active patient records reviewed, and wound care treatment was not included in the plans of care for 1 (Patient #1) of 4 active patient records reviewed. The failure placed the patients at risk of over-medication, under-medication, and adverse drug reactions, or worsening of wounds. Patient #1:Record review of Patient #1’s clinical record revealed a Plan of Care dated 2/7/2026 to 4/7/2026. The Plan of Care indicated that Patient #1 started on the hospice’s services on 8/11/2025. The Plan of Care listed End-stage Heart Failure (heart is too weak to pump blood through the body effectively) as the terminal diagnosis. The Plan of Care listed Sodium Chloride (sterile solution of salt and water used to clean wounds), telfa (dressing that does not stick to wounds) pads, and wound cleanser as supplies. The Plan of Care contained orders for Patient #1 to receive a skilled nurse visit twice the week of 2/8/2026 then skilled nurse visits once a week. The Plan of Care did not contain orders for wound care. Registered Nurse C conducted a skilled nurse visit on 3/6/2026. Registered Nurse C documented that Patient #1 had ulcers under skin lesion under the skin integrity status of the clinical note. Registered Nurse C documented that Patient #1 had a Stage III pressure sore (wound caused by prolonged pressure to the skin and underlying tissues causing cell death) to the right hip and a Stage II pressure sore (wound caused by prolonged pressure to the skin and underlying tissues causing cell death) on the right buttock. Registered Nurse C documented that wound care was performed according to the plan of care. Registered Nurse C conducted a skilled nurse visit on 3/12/2026. Registered Nurse C documented that Patient #1 had a Stage III pressure sore to the right hip and a Stage II pressure sore to the right buttock. Registered Nurse C documented that wound care was performed according to the plan of care. Registered Nurse C conducted a skilled nurse visit on 3/18/2026. Registered Nurse C documented that Patient #1 had a Stage III pressure sore to the right hip and a Stage II pressure sore to the right buttock. Registered Nurse C documented that wound care was performed according to the plan of care. Registered Nurse C conducted a skilled nurse visit on 3/26/2026. Registered Nurse C documented that Patient #1 had a Stage III pressure sore to the right hip and a Stage II pressure sore to the right buttock. Registered Nurse C did not document that wound care was performed. Registered Nurse C conducted a skilled nurse visit on 4/2/2026. Registered Nurse C documented that Patient #1 had a Stage III pressure sore to the right hip and a Stage II pressure sore to the right buttock. Registered Nurse C documented that wound care was performed according to the plan of care and that wound care supplies were provided. Patient #2:Record review of Patient #2’s clinical record revealed a Plan of Care dated 3/16/2026 to 6/13/2026. The Plan of Care indicated that Patient #2 started on the agency’s services on 3/16/2026. The Plan of Care listed Senile Degeneration of the Brain as the terminal diagnosis. The Plan of Care listed Tylenol and Gabapentin as medications used for pain. The Plan of Care included interventions and goals for pain. The Plan of Care listed chronic back pain as an initial patient problem. Registered Nurse E conducted an initial skilled nurse visit on 3/16/2026. Registered Nurse E documented that Patient #2’s pain was controlled with medications; documented Patient #2 had a pain pump in the right abdominal region; documented that the family reported that the pump contained Fentanyl (used to treat severe, acute and chronic pain), Hydromorphone (used to treat moderate to severe pain), and Bupivacaine (anesthetic used to block nerve impulses, causing numbness in specific areas for pain relief). The Plan of Care did not include Fentanyl, Hydromorphone, and Bupivacaine. Patient #4:Record review of Patient #4’s clinical record revealed a Plan of Care dated 2/14/2026 to 4/24/2026. The Plan of Care indicated that Patient #4 started on the agency’s services on 2/24/2026. The Plan of Care listed Atherosclerotic Heart Disease of Native Coronary Artery Chronic condition where plaque builds up the the heart arteries (blood vessel) reducing blood flow to the heart muscle) without Angina Pectoris (chest pain) as the terminal diagnosis. Patient #4’s Plan of Care did not contain medications. The surveyor received a phone call from a Confidential Witness and subsequent email that included a photo of medication bottles and a document that listed medications with Patient #4’s name on them. The photo showed the following medication bottles- Tylenol Rapid Relief 500 mg tablets- used to treat pain/fever, Sleep Quick- Melatonin 10 milligrams - used to regulate sleep, Divalproex 250 milligrams- used to treat seizures (abnormal electrical activity in the brain temporarily affecting consciousness, muscle control and behavior) and migraine (intense throbbing pain of the head lasting from hours to days) headaches, Clonidine (used to treat high blood pressure- the condition of the force of the blood against artery- blood vessel, walls being consistently too high) 0.1milligrams, Trazodone (used to treat major depressive disorder- persistent sadness, loss of interest or pleasure, and impaired daily functioning) 50 milligrams, Pantoprazole (used to reduce acid production in the stomach), Levothyroxine (used to treat condition where the thyroid gland does not produce enough thyroid hormone), another bottle with Melatonin 10 milligrams, and Cyclobenzap- the rest of the medication name was not visible, and a cough and congestion medication- name of medication not readable. The photo included a document of a list of medications with the name of Facility X on it. The document listed the following medications: Divalproex, Trazodone, Pantoprazole, Clonidine, Melatonin, and Levothyroxine. During an interview on 4/15/2026 at 11:10 AM with Registered Nurse E, the surveyor asked if Registered Nurse E performed Patient #2’s admission and what had occurred during the visit. Registered Nurse E informed the surveyor that Registered Nurse E had conducted the admission visit; some of Patient #2’s family were present; that Patient #2 had a pain pump. The surveyor asked Registered Nurse E why the pain pump medications were not included in the Plan of Care. Registered Nurse E stated, “I did the initial visit. The family did not have that information (pain pump medications) on hand. The surveyor asked who would be responsible for obtaining that information later. Registered Nurse E stated, “The other nurses would take over.” During an interview on 4/15/2026 at 2:15 PM, with the Former Home Owner of the home that Patient #4 lived in, the surveyor asked whether Patient #4 took any medications. The Former Home Owner stated, “(Patient #4) was taking medication. When (Patient #4) got on hospice, I know I was hands off after that.” During an interview on 4/15/2026 at approximately 4:15 PM with the Administrator/Supervising Nurse, the surveyor discussed Patient #2’s pain pump medications were not included in the Plan of Care, Patient #4’s medications were not included in the Plan of Care, and Patient #1’s wound care treatments were not included in the Plan of Care. The surveyor asked if Patient #4 took medications. The Administrator/Supervising Nurse stated, “Yes, (Patient #4) takes medications. The surveyor asked who would be responsible for ensuring that the medications/treatments were in the Plans of Care. The Administrator/Supervising Nurse stated, “The admitting nurse, then falls to the case manager.” The surveyor asked why drugs/treatments were not included in the plans of care. The Administrator/Supervising Nurse did not know why it was not included in the plans of care but stated, “It should be there.” The surveyor asked who would be responsible to ensure these were on the Plans of Care. The Alternate Administrator/Supervising Nurse stated, “The RN (registered nurse) case manager,” The surveyor discussed that Registered Nurse C documented in the clinical notes for Patient #1; “Wound care performed per plan of care.” The Administrator/Supervising Nurse informed the surveyor that the nurses were supposed to document the wound care that was performed. The surveyor asked what the current wound care for Patient #1 was. The Administrator/Supervising Nurse provided a copy of faxed documents dated 4/14/2026 from Wound Care Agency A. The documents contained orders for the wound care to Patient #1’s right buttock/sacral (lower back) and right hip wounds. The wound care order contained orders for the following wound care: Right buttock/sacral wound was to be cleaned with Vashe (wound cleanser used for cleaning, irrigation, and moistening wounds) or wound cleanser, prep skin surrounding the wound with skin prep (used to protect the skin around the wound), apply Calcium Alginate (absorbs drainage), lightly pack the wound with gauze, Silvasorb (water-based gel used to treat infected or at risk wounds) and cover with a bordered foam dressing; Right hip clean with Vashe or wound cleanser, skin prep to the skin surrounding the wound, apply calcium alginate, pack with gauze, Silvasorb, and cover with a bordered foam dressing. The surveyor asked who the registered nurse case manager was. The Administrator/Supervising Nurse stated, “(Registered Nurse C) was the case manager.” Registered Nurse C was not available for interview due to a family emergency and was out of the country. Review of the agency’s policy titled “Plan of Care Process,” last reviewed on 3/16/2025. 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 (plan of care) established by the Hospice Interdisciplinary Group/Team (IDG/IDT)...Procedure...VI. The POC includes, but is not limited to...D. Drugs and treatments necessary to meet the needs of the patient...””

“It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical record reviews revealed that the agency did not ensure the hospice designated a registered nurse member of the IDG provided coordination of care, ensured continuous assessment of each patient’s and family’s needs, and ensured the implementation of the interdisciplinary plan of care. CLINICAL RECORD 2/HOME VISIT 2: The Plan of Care from 02/24/2025 to 04/24/2025 included orders to assess skin integrity and the effectiveness of skincare each visit. During the home visit to observe the Registered Nurse (RN) (Personnel Record 2), the patient was not turned to assess the skin condition on the back and buttocks. CLINICAL RECORD 3/HOME VISIT3: The Plan of Care from 02/09/2025 to 04/09/2025 included orders to assess skin integrity and the effectiveness of skincare each visit. During the home visit to observe the RN (Personnel Record 2), the patient was not turned to assess the skin condition on the back and buttocks. In an interview with the Administrator/Director of Nursing (DON) (Personnel Record 2) on 03/20/2025, the administrator/DON stated that the nurse should have turned the patient and assessed the skin.”

“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, interview, and observation. In 1 of 3 (33%) home visit observations revealed that the agency did not ensure that each patient’s individualized written plan of care included interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 2/HOME VISIT 2: The patient elected the hospice benefit on 02/24/2025 with diagnosis of Dysphagia following CNA, Hemiplegia and Hemiparesis, HTN. During the home visit with the registered nurse (RN) (Personnel Record 2), the patient had a diagnosis of a cerebrovascular accident with dysphagia and had a feeding tube with Glucerna 1.2 running at 40ml per hour for 22 hours daily and flushed with water. The order for the tube feeding was not included in the Plan of Care (POC) for the certification period of 02/24/2025 to 04/24/2025 and did not include interventions for aspiration precautions. In an interview with the Administrator/Director of Nursing (DON) (Personnel Record 2) on 03/20/025, the DON stated that the complete orders should have been included, and she believed the EMR was responsible for many of the errors.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions. This standard was not met as evidenced by observation, document review, and interview. In 1 of 3 (33%) home visit observations revealed that the agency did not ensure accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions, such as bag technique. Agency Policy titled Bag Technique IC.60 (09/01/2024) read in part, “When the visit is completed, reusable equipment is cleaned using alcohol, disinfectant wipe and/or antimicrobial soap and water as appropriate, hands are washed, and equipment and supplies are returned to the bag”. Home Visit 2: During the home visit on 03/19/2025 to observe the Registered Nurse (RN) (Personnel Record 2), the RN was observed after using and cleaning the stethoscope to put the stethoscope back into her nursing back without sanitizing her hands. The RN did not observe the agency policy on bag technique. In an interview with the RN (Personnel Record 2) after the visit, the RN stated that she was nervous during the visit.”

“It is required the hospice must provide nursing care and services by or under the supervision of a registered nurse. Nursing services must ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and updated assessments. This standard was not met as evidence by clinical record review, observation and interview. In 1 of 3 (33%) home visit observations revealed that the agency did not ensure the nursing needs of the patient was met. CLINICAL RECORD 3/HOME VISIT 3: The Plan of Care (POC) for the certification period 02/09/2025 to 04/09/2025 included a fall mat as the patient was at high risk for falls. A home visit was conducted on 03/19/2025 to observe the RN (Personnel Record 2). During the visit, there was no fall mat in the patient’s room. In an interview with the RN during the visit, the RN stated that the fall mat was probably in the patient’s former room as the patient recently had a room change. The RN was unable to state when the patient had changed rooms, and no attempt was made to obtain the fall mat as ordered.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group and includes 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 14 (7%) clinical record reviews revealed that the agency did not ensure that hospice aides were assigned to a specific patient by a registered nurse who was a member of the Interdisciplinary Group (IDG) and included written patient care instructions for a hospice aide were prepared by an RN who was responsible for the supervision of the hospice aide. CLINICAL RECORD 3/HOME VISIT 3: The hospice aide care plan effective 04/15/2024 included the task of ambulating the patient with a walker. A home visit was conducted on 03/19/2025 to observe the Registered Nurse (RN) (Personnel Record 2). The patient was not ambulatory and required the assistance of two for transfers. In an interview with the Registered Nurse during the visit on 03/19/2025, the RN stated that the patient was not ambulatory and that this should have been changed.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. 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 7of 14 (50%) clinical record reviews revealed that the agency did not ensure that a patient clinical record containing past and current findings was maintained for each hospice patient and included physician orders. CLINICAL RECORD 1: The Plan of Care (POC) for the certification period 09/17/2024 to 12/17/2024 included a foley catheter 16-20 French with a 5 to 30 ml balloon as needed, but did not include an indication for use. There was no documented evidence that the plan of care included a description of the patient’s medical signs and symptom for the as needed foley catheter. CLINICAL RECORD 2: The Plan of Care for the certification 02/24/2025 to 04/24/2025 included an order for oxygen two (2) to five (5) LPM as needed (2-5 LPM), and oxygen 2 LPM continuously as needed for shortness of breath was included on the medication profile. The Plan of Care included an order for a Dietician to evaluate. The Dietician evaluated the patient on 02/25/2025 and recommended Banatrol Plus, one to two packs per day via enteral feedings for diarrhea. The patient was taking the Banatrol, however the order was not added to the Plan of Care (POC) and there was no subsequent physician order for the Banatrol. CLINICAL RECORD 4: The Plan of Care for the certification period of 01/24/2025 to 04/24/2025 included Lorazepam 1.75mg per ml, 0.5ml as needed for anxiety/agitation (effective 01/25/2025) and Zofran 4mg oral as needed for nausea and vomiting was included however, the plan of care orders did not include a frequency for these medications. CLINICAL RECORD 5: The Plan of Care for the episode 10/30/2024 to 12/28/2024 included Lorazepam 1.75mg PO as needed for anxiety/agitation and Zofran 4mg PO as needed for nausea/vomiting however, the plan of care orders did not include a frequency for these medications. CLINICAL RECORD 6: The Plan of Care for the episode 12/05/2024 to 02/02/2025 included Lorazepam 1.75mg PO as needed for anxiety/agitation, Zofran 4mg PO as needed for nausea/vomiting, Atropine 0.75% drops, two drops oral as needed for secretions, Bisacodyl 10 mg suppositories one as needed for constipation, and Morphine Sulfate 20mg per ml give 0.25ml as needed for pain or shortness of breath however, the plan of care orders did not include a frequency for these medications. CLINICAL RECORD 7: The Plan of Care for the episode 02/28/2025 to 05/28/2025 included Lorazepam 1.75mg PO as needed for anxiety/agitation, Zofran 4mg PO as needed for nausea/vomiting, however, the plan of care did not include a frequency for these medications. The Plan of Care also included Refresh Tears solution one time a day for dry eyes and Systane solution one time a day for dry eyes however the order did not include which eye or both eyes. CLINICAL RECORD 10: The Plan of Care for the certification period of 11/17/2024 to 01/15/2025 included oxygen 2% of 2 lpm continuously as needed for shortness of breath. The dose was incorrect at 2% as that is not measurable via the oxygen concentrator. In an interview with the Administrator/Director of Nursing (DON) (Personnel Record 2) on 03/20/2025, the administrator/DON stated that the nurses had not completed the orders but that they should have and that the nurses had a difficult time with the computer system.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: Hospice medication information. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 2 (50%) home visit observations performed at a facility revealed that the agency did not ensure that facility was provided all patient medication information. CLINICAL RECORD 3/HOME VISIT 3: A home visit to the assisted living facility where the patient resided was conducted on 03/19/2025 to observe the Registered Nurse (RN) (Personnel Record 2). A review of the medications the assisted living facility (ALF) was giving the patient, and the hospice medication profile was compared. The Plan of Care (POC) for the certification period 02/09/2025 to 04/09/2025 included Acetaminophen 500 mg PO every eight (effective 04/12/2024) hours as needed, Acetaminophen suppository 650mg rectally as needed for fever or pain, Atropine 0.75% drops, two drops sublingual as needed for secretions, Bisacodyl 10mg suppository one rectal as needed for constipation, Lorazepam 1.75mg per ml, give 0.5ml PO as needed for anxiety/agitation, Morphine Sulfate 20mg per ml, give 0.25ml as needed for pain or SOB and Tylenol Extra Strength 500 mg tabs, take two tablets every eight hours as needed. These medications were not on the assisted living medication administration record or orders. The hospice medication profile did not include a frequency for the Acetaminophen 650mg rectal suppositories, Atropine 0.75% give two drops for secretions, Bisacodyl 10 mg rectal suppository, Lorazepam 1.75mg per ml, give 0.5ml as needed for agitation and restlessness, the morphine sulfate 20mg per ml, give 0.25ml for pain and/or shortness of breath. Tylenol Extra Strength 500mg, two tablets every eight hours as needed did not include the indication for use. The ALF orders also included Donepezil 10mg PO daily (effective 05/21/2024). The hospice POC did not include the Donepezil. In an interview with the Administrator/Director of Nursing (DON) (Personnel Record 2) on 03/20/025, the DON stated that the complete orders should have been included, and she believed the EMR was responsible for many of the errors.”

“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 IS A CONTINUED REQUIRED ACTION This standard was not met as evidenced by clinical record review and interview. In 3 of 5 (60%) of the clinical records reviewed revealed that the agency did not ensure that each patient had an individualized plan of care that addressed the patient-specific needs. Clinical Record 1: The plan of care dated 10/17/2023 stated Foley catheter PRN but did not include any individualized specific instruction related to the size of the catheter or balloon or how often to change. There was no documented evidence of additional orders since the last site visit dated 10/24/2023. Clinical Record 4: The plan of care dated 10/9/2022 did not include any medications and duration of visits ordered. There was no documented evidence of any plan of care updates or revisions since 10/24/23. Clinical Record 5: The plan of care dated 10/25/2023 stated Foley catheter PRN. There was no documented evidence of individualized interventions for the catheter size or balloon, frequency of changing and the order for the orders for a Laxative/enema of choice PRN with no specific medication or dosage listed. In an interview on 12/5/2023 DON stated in part, “the last site visitor directed the agency not to fix prior care plans and just to wait until patients are recertified. We are going to fix it by just using the EMR instead of the paper forms that the consultant told us to use.” THIS IS A CONTINUED REQUIRED ACTION 3 of 5 (60%) of the clinical records reviewed revealed that the agency did not ensure that each patient had an individualized plan of care that addressed the patient-specific needs.”

“It is required that a hospice aide provides services as ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 4 (75%) clinical records reviewed with home health aide services revealed that the agency did not ensure that the aides followed the plan of care. THIS IS A CONTINUED REQUIRED ACTION. In 3 of 4 (75%) of clinical records reviewed with home health aide services revealed that the agency did not ensure that the aides followed the plan of care. Clinical Record 1: The aide care plan by Registered Nurse (RN) dated 10/17/2023 included, “bathroom assistance, document output, light housekeeping bedroom and bathroom, encourage fluids, clothing assist, foot care, oral care. shampoo, shower. The aide visit note lists the task and next to the task are two boxes; acknowledged and completed. The aide visit note dated 12/4/2023 acknowledged bathroom assistance, document output, light housekeeping bedroom and bathroom, encourage fluids, clothing assist, foot care, oral care. shampoo, shower however did not mark them complete. There was no documented evidence that the aide completed those tasks. The aide note did not include any documented evidence that the RN was notified of assigned tasks that were not completed. Clinical Record 2: The aide plan of care by the RN dated 08/02/2023 assigned task included to: assist with feeding, encourage fluids, foot care and nail care. The aide visit note dated 12/4/2023 had two boxes next to each task; acknowledged and completed. The aide documented on visit note dated 11/29/2023 that assist with feeding, encourage fluids, foot care and nail care were acknowledged however were not documented as completed. The aide note did not include any documented evidence that the RN was notified of assigned tasks that were not completed. Clinical Record 4: The aide plan of care by the RN dated 10/11/23 included: document output, assist with feeding, encourage fluids, foot care and nail care. The aide visit note dated 10/13/2023 had two boxes next to each task; acknowledged and completed. The aide documented on visit note dated 10/13/2023 that document output, assist with feeding, encourage fluids, foot care and nail care were acknowledged however were not documented as completed. The aide note did not include any evidence that the RN was notified of assigned tasks that were not completed. In an interview on 12/6/2023 with the Director of Nurses (DON) confirmed that home health aide notes did not include completion of all tasks assigned. It is required that a hospice aide provides services as ordered by the Interdisciplinary Group and included in the plan of care. THIS IS A CONTINUED REQUIRED ACTION. In 3 of 4 (75%) of clinical records reviewed with a home health aide revealed that the agency did not ensure that the aides followed the plan of care.”

“It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. THIS IS A CONTINUED REQUIRED ACTION This standard was not met as evidenced by clinical record review and interview. 1 of 5 (20%) of clinical records reviewed revealed that the agency did not ensure that the physician completed the recertification of terminal illness. Clinical Record 2: The patient elected the hospice benefit on 07/06/2023. There was no documented evidence of a signed physician recertification or plan of care for the certification period beginning 10/04/2023. In an interview on 12/5/2023 with the Director of Nursing (DON), the DON stated in part, “I was told to wait until the following certification period to fix things.” THIS IS AA CONTINUED REQUIRED ACTION 1 of 5 (20%) of clinical records reviewed revealed that the agency did not ensure that the physician completed the recertification of terminal illness.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice, the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. THIS IS A CONTINUED REQUIRED ACTION This standard was not met as evidenced by clinical record review and interview. 1 of 1 (100%) live discharge reviewed revealed that the agency did not ensure that a discharge summary was provided to the attending physician. Clinical Record 5: The patient elected the hospice benefit on 10/25/2023 and was discharged to the hospital on 11/28/2023. There was no documented evidence that the discharge summary in the clinical record was sent to the patient’s attending physician. The discharge summary dated 11/28/2023 read in part, “ Patient attending physician notified – No.” In an interview on 12/5/2023 with the Director of Nursing (DON), the DON confirmed that the EMR documentation noted that the physician was not notified of discharge and there was no evidence of providing the physician with a discharge summary. THIS IS A CONTINUED REQUIRED ACTION: 1 of 1 (100%) live discharges reviewed revealed that the agency did not ensure that a discharge summary was provided to the attending physician.”