Hospice Services Inc.

“Based on record review and interview, the hospice failed to include all services necessary for the palliation and management of the terminal illness and related conditions, including the drugs and treatment necessary to meet the needs of the patient, in that the plan of care did not include wound care treatment to be provided for 1 (#4) of 2 patient records reviewed that received wound care. The failure place Patient #4 at risk of inappropriate care that could cause a wound infection or the wound worsening. Patient #4:Review of Patient #4’s patient record revealed an Initial Plan of Care/Physicians orders dated 6/10/2024 to 9/8/2024. The Plan of Care listed Cerebral Vascular Accident with Weakness to the Left Side (loss of blood flow to part of the brain that can cause lasting brain damage, long-term disability, or even death) as the terminal diagnosis. The Initial Plan of Care did not include wound care treatment. The Interdisciplinary Plan of Care dated 6/13/2024 did not include wound care treatment. Review of Patient #4’s patient record did not reveal a physician order for wound treatment. Registered Nurse C conducted an Initial Comprehensive Assessment skilled nurse visit on 6/10/2024. Registered Nurse C documented in the Integumentary (skin, hair, nails, and glands) portion of the skilled nursing note. Registered Nurse A documented that Patient #4 had signs of skin break down (damage to the skin) and had a pressure ulcer (localized injury to the skin and underlying tissues that developed from prolonged pressure applied to an area). Registered Nurse C did not document an assessment of the wound. Registered Nurse C marked a “X” on a body diagram indicating the pressure sore was on back of the left lower leg. Registered Nurse C documented that Patient #4 had pain with the wound dressing change. Registered Nurse C documented that wound care was completed per physician order. Registered Nurse C conducted a skilled nursing visit on 6/12/2024. Registered Nurse C documented that Patient #4 refused wound care. Registered Nurse C documented “awaiting physician for wound care orders.” Patient #4’s record contained an Interdisciplinary Plan of Care dated 6/13/2025. The Interdisciplinary Plan of Care indicated that Patient #4 had a wound to the back area of the lower right leg. The Interdisciplinary Plan of Care contained an intervention that listed “Wound care orders per physician order.” Registered Nurse C conducted a skilled nurse visit on 6/20/2024. Registered Nurse C documented performing wound care. Registered Nurse C documented cleaning the wound with wound spray; allowed to air dry; applied an antibiotic ointment (used to kill bacteria or prevent bacteria from growing); applied an abdominal pad (large, thick pads that can absorb a large amount of wound drainage), and secured with Coban (self-adherent, cohesive elastic wrap used for compression, support, and to secure dressings). Registered Nurse C conducted a skilled nurse visit on 6/24/2024. Registered Nurse C documented performing wound care. Registered Nurse C documented cleaning the wound with wound care spray; allowed to air dry; applied antibiotic; covered with 2 by 2 gauze followed by an abdominal pad; and secured with Coban. Registered Nurse C was no longer employed at the agency and was not available for interview. During an interview on 9/26/2025 at 11:12 a.m. with the Administrator/Medical Director and the Supervising Nurse, the surveyor discussed Patient #4’s patient record and that the Plan of Care did not include wound treatment. The surveyor asked who would be responsible for including treatments in the Plan of Care. The Supervising Nurse informed the surveyor that the admitting nurse would be responsible for writing physician orders at admit for the Plan of Care and a nurse that received an order from the physician would be responsible to include it in the Plan of Care. The surveyor asked what the agency’s policy regarding treatments in the Plan of Care. The Supervising Nurse informed the surveyor that the Supervising Nurse could not quote the policy but would contact the physician and would write the order “right then.” The surveyor asked why the wound treatment was not included in the Plan of Care. The Supervising Nurse stated, “I don’t know.” The surveyor asked the Administrator/Medical Director if the Administrator/Medical Director had ordered wound care for Patient #4. The Administrator/Medical Director stated, “Yes.” The Administrator/Medical Director and the Supervising Nurse were asked why the policy wasn’t followed. The Administrator/Medical Director and the Supervising Nurse informed the surveyor that they did not know why it wasn’t followed. The Administrator/Medical Director and the Supervising Nurse did not dispute the finding. Review of the agency’s policy titled “Plan of Care Process,” labeled PC.30, and last reviewed on 9/1/2024 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...III. The Hospice will review and revise patient care in accordance with changes in the patient’s condition; spiritual status, psychosocial status, residential environment; patient’ response to care; and changes that have occurred regarding diagnosis, treatment, medication, precautions, and limitations. Procedure I. Information will be gathered from the initial assessment and be used by the Hospice to develop the Initial Plan of Care (IPOC)/Physician’s orders...C. The Hospice Nurse will review all medications (including prescription, over the counter, herbal remedies, or alternative treatments) and treatments (I.e., wound care, ostomies, foley care etc)...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 hospice failed to include an election statement that was in accordance with the Code of Federal Regulations 418.24 in the patient record; in that the effective date of election for hospice care was blank on the election statement in 3 (#5, #6, #7) of 7 patient records reviewed. The failure placed the patients’ at risk of a delay in hospice services. Review of Code of Federal Regulations, Title 42 Chapter IV, Subchapter B, Part 418, Subpart B, 418.24 read in part; “Election of Hospice Care... (b) Content of the Election Statement. The election statement must include the following..(4) The effective date of the election, which may be the first day of hospice care or a later date, but may be no earlier than the date of the election statement...” Patient #5:Review of Patient #5’s clinical record revealed an Initial Plan of Care dated 7/20/2024. The Plan of Care indicated that Patient #5 started on the hospice’s services on 7/20/2024. The Plan of Care listed Cirrhosis of the Liver (chronic liver disease characterized by the formation of scar tissue in the liver) as the terminal diagnosis. Patient #5’s record contained a document titled “Hospice Informed Consent/Election of Hospice Benefit.” The document contained a fill in the blank area that read in part;... “I acknowledge and understand the above, and authorize Medicare Hospice coverage to be provided by (the Hospice) (blank) with the effective date of election to begin on (blank).’ The effective date of election to begin Medicare hospice coverage was left blank. Patient #6:Review of Patient #6’s clinical record revealed an Initial Plan of Care dated 4/8/2024 to 7/6/2024. The Plan of Care indicated that Patient #6 started on the hospice’s services on 4/8/2024. The Plan of Care listed Senile Degeneration of the Brain (decline in mental processes of thinking, learning, remembering, and judging that occurs with age) as the terminal diagnosis. Patient #6’s clinical record contained a document which read in part;... “Required signatures for the election of the hospice benefit...I acknowledge and understand the above, and authorize Medicare hospice coverage to be provided by (blank) with the effective date of election to begin on (blank)...” The effective date of election to begin Medicare hospice coverage was left blank. Patient #7:Review of Patient #7’s clinical record revealed an Initial Plan of Care dated 7/26/2024 to 10/23/2024. The Plan of Care indicated that Patient #7 started on the hospice’s services on 7/26/2024. The Plan of Care listed Severe Dementia (advanced stage of decline in memory, reasoning, language) as the terminal diagnosis. Patient #7’s clinical record contained two documents with each reading in part;... “required signatures for the election of the hospice benefit...I acknowledge and understand the above, and authorize Medicare hospice coverage to be provided by (blank) with the effective date of election to begin on (blank)...” The effective date of election to begin Medicare hospice coverage was left blank on both documents. During an interview on 9/26/2025 at 11:12 a.m. with the Administrator/Medical Director and the Supervising Nurse, the surveyor discussed the date of election on the election statements were blank. The surveyor asked who would be responsible for the election statements, filling out the information on the statements. The Supervising Nurse stated, “The nurse that does the admission would fill out the forms.” The surveyor asked how would the nurse know what the patient dates of election would be. The Administrator/Medical Director informed the surveyor that the biller would notify the nurse in a communication, this was done when the biller verified the benefits. The surveyor asked who was responsible to ensure that the date of election was included. The Supervising Nurse stated, “I try to make sure that I include it.” The surveyor asked the Supervising Nurse if the Supervising Nurse knew why the date of election was left blank on the forms (Supervising Nurse was the admitting nurse). The Supervising Nurse stated, “No, I don’t. I thought that I did it.” The Administrator/Medical Director and the Supervising Nurse did not dispute the finding. Review of the agency’s policy titled “Eligibility and Election of the Medicare Hospice Benefit,” labeled PE.25, and last reviewed on 10/1/2024 read in part; “Purpose To provide guidelines and processes for eligibility and election of the Medicare Hospice Benefit... Policy...II. A signed copy of the election statement will be retained in the clinical record...VII. Content of the election statement A. The election statement will include: 4. The date of “election of hospice care”...”

“Based on record review and interview, the hospice failed to include physician orders for wound care in the patient’s record for 1 (#4) of 2 patient records reviewed where the patient received wound care from the agency’s nurses. The failure placed Patient #4 at risk for inappropriate care that could result in infection or the wound worsening. Patient #4:Review of Patient #4’s patient record revealed an Initial Plan of Care/Physicians orders dated 6/10/2024 to 9/8/2024. The Plan of Care indicated that Patient #4 started on the agency’s services on 6/10/2024. The Plan of Care listed Cerebral Vascular Accident with Weakness to the Left Side (loss of blood flow to part of the brain that can cause lasting brain damage, long-term disability, or even death) as the terminal diagnosis. The Plan of Care contained an order for Patient #4 to receive skilled nurse visits one time each week and as needed. The Initial Plan of Care did not contain a physician order for wound care. The Interdisciplinary Plan of Care dated 6/13/2024 did not contain a physician order for wound care. Review of Patient #4’s patient record did not reveal a physician order for wound care. Registered Nurse C conducted an Initial Comprehensive Assessment skilled nurse visit on 6/10/2024. Registered Nurse C documented in the Integumentary (skin, hair, nails, and glands) portion of the skilled nursing note. Registered Nurse A documented that Client #4 had signs of skin break down (damage to the skin) and had a pressure ulcer (localized injury to the skin and underlying tissues that developed from prolonged pressure applied to an area). Registered Nurse C did not document an assessment of the wound. Registered Nurse C marked a “X” on a body diagram indicating the pressure sore was on back of the left lower leg. Registered Nurse C documented that Patient #4 had pain with the wound dressing change. Registered Nurse C documented that wound care was completed per physician order. Registered Nurse C conducted a skilled nursing visit on 6/12/2024. Registered Nurse C documented that Patient #4 refused wound care. Registered Nurse C documented “awaiting physician for wound care orders.” Patient #4’s record contained an Interdisciplinary Plan of Care dated 6/13/2025. The Interdisciplinary Plan of Care indicated that Patient #4 had a wound to the back area of the lower right leg. The Interdisciplinary Plan of Care contained an intervention that listed “Wound care orders per physician order.” Registered Nurse C conducted a skilled nurse visit on 6/20/2024. Registered Nurse C documented performing wound care. Registered Nurse C documented cleaning the wound with wound spray; allowed to air dry; applied an antibiotic ointment (used to kill bacteria or prevent bacteria from growing); applied an abdominal pad (large, thick pads that can absorb a large amount of wound drainage), and secured with Coban (self-adherent, cohesive elastic wrap used for compression, support, and to secure dressings). Registered Nurse C conducted a skilled nurse visit on 6/24/2024. Registered Nurse C documented performing wound care. Registered Nurse C documented cleaning the wound with wound care spray; allowed to air dry; applied antibiotic; covered with 2 by 2 gauze followed by an abdominal pad; and secured with Coban. Registered Nurse C was no longer employed with the agency and not available for interview. During an interview on 9/26/2025 at 11:12 a.m. with the Administrator/Medical Director and the Supervising Nurse, the surveyor discussed Patient #4’s patient record and that the patient record did not include physician orders for wound care. The surveyor asked who would be responsible for writing physician orders. The Supervising Nurse informed the surveyor that the admitting nurse would be responsible for writing physician orders at admission. The surveyor asked what the agency’s policy regarding physician orders was, what time frame should they be written and included in the patient record. The Supervising Nurse informed the surveyor that the Supervising Nurse could not quote the policy but would contact the physician and would write the order “right then.” The surveyor asked why the order was not included in the patient record. The Supervising Nurse stated, “I don’t know.” The surveyor asked the Administrator/Medical Director if the Administrator/Medical Director had ordered wound care for Patient #4. The Administrator/Medical Director stated, “Yes.” The Administrator/Medical Director and the Supervising Nurse were asked why the policy wasn’t followed. The Administrator/Medical Director and the Supervising Nurse informed the surveyor that they did not know why it wasn’t in Patient #4’s record. The Administrator/Medical Director and the Supervising Nurse did not dispute the finding. Review of the agency’s policy titled “Medical Record Content,” labeled IM.30, and last reviewed on 9/1/2024 read in part; “Purpose To ensure each medical record contains complete, correct information which identifies the patient, describes problems, and needs of the patient, justified patient care, and accurately describes care provided, outcomes, significant events, and continuity/coordination of care. Policy I. The Hospice will initiate and maintain an individual and accurate medical record containing past and current information for each patient accepted for care. The record will contain correct clinical information that is available to the patient’s attending physician and hospice staff. The Medical record will be in compliance with all federal and state laws and regulations...Procedure I. The content of the medical record will include, at a minimum...J. Physician orders...”