Amici Hospice LLC

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 6 (17%) clinical records reviewed, the agency did not ensure an accurate review of medications the patient was currently using to identify any potential adverse effects and drug reactions. CLINICAL RECORD 2/HOME VISIT 2: The patient elected the hospice benefit on 05/27/2025 with a terminal diagnosis of malignant neoplasm of the prostrate. During the home visit observation on 07/01/2025 with the Registered Nurse (Personnel Record 2), a medication review was completed by comparing the hospice medication profile to the patient’s home medications. The patient’s home medications included a prescription bottle of Morphine Sulfate ER 60 mg every 12 hours for pain. The patient’s spouse stated that the patient was being administered this prescription. The hospice medication profile dated 05/27/2025 to 07/01/2025 did not include Morphine Sulfate and Morphine Sulfate was not included in the patient’s medication review. During the home visit the Registered Nurse (Personnel Record 2) verified that an order had been received for the Morphine Sulfate and that the patient was taking the medication. The RN verified that the medication was not included in the patient’s medication profile and stated she had missed adding it in.”

“It is required that each patient’s individualized written plan of care Includes all services necessary for the palliation and management of the terminal illness, including the following: measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) clinical records reviewed, the agency did not ensure the individualized written plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 1: The patient elected the hospice benefit on 05/30/2025 with a terminal diagnosis of neurocognitive disorder with Lewy bodies. Clinical record review revealed that the patient was having “increased sleeping” and had been diagnosed with arthritis and was administered Voltaren topical gel for pain. The plan of care dated 05/30/2025 to 07/01/2025 included a goal of “optimal rest status for pt/family/pcg [primary caregiver].” The plan of care also included the goal “pain will remain comfortable level during care.” The goals on the plan of care were not measurable when they did not include the patient’s acceptable level of pain to remain comfortable and what optimal rest would be for the patient. During an interview on 07/01/2025, the Alternate Director of Nursing (Personnel Record 2) stated that the goals included in the plan of care were not measurable.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, observation, and interview. In 1 of 3 (33%) home visit observations, the agency did not ensure staff performed hand hygiene as required by agency policy. Agency policy No. 7-009 Hand Hygiene, required in part, “Hand decontamination using an alcohol-based hand rub should be performed: G. After removing gloves.” HOME VISIT 1: During home visit observation on 07/01/2025 with the Hospice Aide (HA) (Personnel Record 1), the HA was observed to don (apply) gloves and washed the upper part of the patient’s body and then removed gloves. The HA then donned another pair of gloves without sanitizing hands after glove removal. During an interview and review of the home visit with the Alternate Director of Nursing (ADON) (Personnel Record 2) on 07/01/2025, the ADON stated that the HA did not follow the agency policy to sanitize hands after removing gloves.”

“It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address informing local and state emergency officials of any on-duty employees that the hospice is unable to contact. This standard was not met as evidenced by document review and interview which revealed the Emergency Plan lacked documented evidence of a plan to be able to inform local and state emergency officials in the event any on-duty employee was unable to be reached. Document: Agency Emergency Plan In an interview with the Governing Body Vice President/Human Relations (Personnel Record 7) and the Alternate Administrator/Alternate Disaster Coordinator/Chief Executive Officer/Governing Body President (Personnel Record 10) on 11/26/2024, they agreed that they did not have in their EP Plan about how/when/who for contacting emergency officials about any on-duty staff that were unreachable during an emergency situation. Upon reviewing the Emergency Plan, the documentation lacked evidence of a plan to be able to inform local and state emergency officials in the event any on-duty employee was unable to be reached. In an interview with the Governing Body Vice President/Human Relations (Personnel Record 7) and the Alternate Administrator/Alternate Disaster Coordinator/Chief Executive Officer/Governing Body President (Personnel Record 10) on 11/26/2024, that the agency did not have any documentation in the EP Plan about contacting emergency officials about any on-duty staff that were unreachable during an emergency situation.”

“It is required that the hospice implements emergency preparedness (EP) policies and procedures based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address arrangements with facilities and other providers to receive patients to maintain the continuity of care to patients. This standard was not met as evidenced by document review and interview which revealed that the Emergency Plan and the agency’s contracts lacked evidence that the hospice had arrangements with facilities and/or other providers to maintain continuity of care in the case the agency was impacted and limited in what services it could provide or if it ceased to be able to function to care for the patients. Documents: Agency Emergency Plan Documents: Agency Contracts In an interview with the Governing Body Vice President/Human Relations (Personnel Record 7) and the Alternate Administrator/Alternate Disaster Coordinator/Chief Executive Officer/Governing Body President (Personnel Record 10) on 11/26/2024, they stated the agency did not have any arrangements with another hospice to receive their patients in case of emergency and confirmed that they needed to and could/would get one in place Upon reviewing the Emergency Plan and the agency’s contracts, the documentation lacked evidence that the hospice had arrangements with facilities and/or other providers to maintain continuity of care in the case the agency was impacted and limited in what services it could provide or if it ceased to be able to function to care for the patients. In an interview with the Governing Body Vice President/Human Relations (Personnel Record 7) and the Alternate Administrator/Alternate Disaster Coordinator/Chief Executive Officer/Governing Body President (Personnel Record 10) on 11/26/2024, that the agency did not have any arrangements with another hospice to receive their patients in case of emergency.”

“It is required that the hospice provides information on advance directives upon initiation of hospice care. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 7 (29%) clinical records reviewed revealed that the agency did not ensure that the hospice provided information about advance directives upon the patient’s start of care. Document 1: Comprehensive Assessment (Policy No. 1-014) October 2019 “... During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient’s clinical record, including ...Presence of any Advance Directives for care and/or discussion with patient and family/caregiver regarding withholding of resuscitative services ... Clinical Record 6: The patient elected hospice care on 02/06/2024. A review of the clinical record revealed no documented evidence that the patient received written information on advance directives upon initiation of hospice care. Clinical Record 7: The patient elected hospice care on 05/08/2024. A review of the clinical record revealed no documented evidence that the patient received written information on advance directives upon initiation of hospice care. During an interview on 11/26/2024 with the Governing Body Vice President and Director of Human Relations (Personnel Record 7) and the Alternate Administrator/Chief Executive Officer/Governing Body President (Personnel Record 10), the findings were confirmed, and no additional documentation was provided prior to the end of the site visit. The patients were all admitted and discharged prior to the current leadership assuming control of the agency on 10/20/2024.”

“It is required that during the initial assessment visit and in advance of providing care, the hospice provides the patient—or his or her representative—with verbal (meaning spoken) and written notice of the patient’s rights and responsibilities. This information is provided in a language and manner that the patient understands. The hospice obtains the patient’s or representative’s signature confirming that he or she received a copy of the Bill of Rights and Responsibilities statement. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 7 (29%) clinical records reviewed revealed that the agency did not ensure that the patient was provided with a signed acknowledgment of receipt of the notice of the patient’s rights and responsibilities. Initial Assessment (Policy No. 1-013) October 2019 “...Admitting registered nurse will provide the patient or patient representatives a verbal and written notice of the patient’s bill of rights ...” Clinical Record 6: The patient’s date of election was 02/06/2024. The record lacked documented evidence of the patient or representative receiving a copy of the Bill of Rights. Clinical Record 7: The patient’s date of election was 05/09/2024. The record lacked documented evidence of the patient or representative receiving a copy of the Bill of Rights. During an interview on 11/26/2024 with the Governing Body Vice President and Director of Human Relations (Personnel Record 7) and the Alternate Administrator/Chief Executive Officer/Governing Body President (Personnel Record 10), the findings were confirmed, and no additional documentation was provided. The patients were all admitted and discharged prior to the current leadership assuming control of the agency on 10/20/2024.”

“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, document review and interview. In 2 of 7 (29%) clinical records reviewed revealed the agency did not ensure that the frequency orders in the patient’s plan of care were implemented as ordered. Document 1: Interdisciplinary Group Coordination of Care (Policy No. 1-035) October 2019 “...utilize a case system ... The Case Manager will be responsible for the coordination of services with the interdisciplinary group ... will be responsible for cooperative care planning..” Missed Visits (Policy No. 1-027) October 2019 “... Missed visits will be communicated to the Interdisciplinary Group at the IDG Meeting... Missed visits will be documented in the clinical record .. If a visit is missed and not rescheduled, the clinician will notify the IDG and clinical supervisor of the missed visit and the reason for the missed visit. Document in the patient’s clinical record ... date and type of visit that was missed, reason for the missed visit ...” Clinical Record 4: The patient elected hospice care on 02/06/2024 and was administratively discharged on 06/11/2024. A review of the plans of care for 02/06/2024 to 05/05/2024 and 05/06/2024 to 08/03/2024 included orders for the Spiritual Care Counselor to visit the patient once a month. A clinical record review revealed no documented spiritual care visits for March, April, and May. There was no evidence of documented missed visits or communication with the patient or physician. Clinical Record 5: The patient elected the hospice benefit on 04/02/2024 and was administratively discharged on 06/11/2024. A review of the plan of care for 04/02/2024 to 06/30/2024 included orders for the Spiritual Care Counselor to visit the patient once a month. A clinical record review revealed no documented spiritual care visits for April and May. There was no evidence of documented missed visits or communication with the patient or physician. During an interview on 11/26/2024 with the Governing Body Vice President and Director of Human Relations (Personnel Record 7) and the Alternate Administrator/Chief Executive Officer/Governing Body President (Personnel Record 10), confirmed the finding and could provide no additional documentation. The patients were all admitted and discharged prior to the current leadership assuming control of the agency on 10/20/2024.”

“It is required that each patient’s individualized written plan of care reflects patient, and family goals and 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 and interview. In 2 of 7 (29%) clinical records reviewed revealed the agency did not ensure that the patient’s plan of care reflected identified problems, goals, and interventions based on the assessment data documented in the clinical record. Clinical Record 5: The patient elected hospice care on 04/02/2024 with the primary hospice diagnosis of senile degeneration of the brain. The initial comprehensive assessment completed by the Registered Nurse (RN) on 04/02/2024 documented that the patient had memory loss, a pacemaker, received insulin, and used a glucometer. The initial Social Worker assessment dated 04/04/2024 documented that the patient had no funeral plans. The plan of care for 04/02/2024 to 06/30/2024 did not document problems, interventions, and goals related to the patient’s memory loss, pacemaker, insulin dependence, glucometer management, and funeral planning. Clinical Record 6: The patient, with a diagnosis of atherosclerotic heart disease, elected hospice care on 02/06/2024 and revoked hospice care on 03/04/2024. The RN comprehensive assessment dated 02/13/2024 documented that the patient had edema to the lower extremities, fatigued easily, had bladder incontinence, and impaired mobility. The plan of care for 02/06/2024 to 05/05/2024 did not document problems, interventions, and goals for edema, fatigue, bladder incontinence, and impaired mobility. During an interview on 11/26/2024 with the Governing Body Vice President and Director of Human Relations (Personnel Record 7) and the Alternate Administrator/Chief Executive Officer/Governing Body President (Personnel Record 10), the findings were confirmed, and no additional documentation was provided. The patients were all admitted and discharged prior to the current leadership assuming control of the agency on 10/20/2024.”

“It is required that the hospice develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program. The hospice governing body is responsible for ensuring that the program includes defined data detail and frequency of collection and approves such. This standard was not met as evidenced by document review and interview revealed upon reviewing the quality assessment and performance improvement (QAPI) program binder and materials and the only Governing Body meeting minutes provided, which were for October and November 2024, revealed that the documentation lacked the evidence of the Governing Body’s approval of the QAPI Plan to ensure the detail and frequency of the data collection to ensure a hospice-wide QAPI program. An interview and extensive conversation with the Governing Body Vice President (Personnel Record 7) and the Administrator/Chief Executive Officer/Governing Body President (Personnel Record 10) on 11/26/2024 confirmed that the Governing Body had not approved a QAPI Plan that documented the frequency and detail of information to be collected for an effective QAPI program. On the evening of 11/26/2024, during the site visit, the Governing Body held a meeting. The plan, which included defined data and a frequency of collection, was compiled and approved by the Governing Body. Upon reviewing the quality assessment and performance improvement (QAPI) program binder and materials and the only Governing Body meeting minutes provided, which were for October and November 2024, it revealed that the documentation lacked the evidence of the Governing Body approved a QAPI Plan to ensure the detail and frequency of the data collection to ensure a hospice-wide QAPI program. An interview and extensive conversation with the Governing Body Vice President (Personnel Record 7) and the Administrator/Chief Executive Officer/Governing Body President (Personnel Record 10) on 11/26/2024 confirmed that the Governing Body had not approved a QAPI Plan that documented the frequency and detail of information to be collected for an effective QAPI program. On the evening of 11/26/2024, the Governing Body held an impromptu meeting. The plan, which included defined data and a frequency of collection, was compiled and approved by the Governing Body.”

“It is required that the hospice uses quality indicator data, including patient care data and other relevant data, in the QAPI program. The frequency and detail of the data collection is approved by the hospice’s governing body. This standard was not met as evidenced by document review and interview revealed upon reviewing the quality assessment and performance improvement (QAPI) program binder and materials and the only Governing Body meeting minutes provided, which were for October and November 2024, it revealed that the documentation lacked the evidence of the Governing Body approved a QAPI Plan to ensure the detail and frequency of the data collection to ensure a hospice-wide QAPI program. An interview and extensive conversation with the Governing Body Vice President (Personnel Record 7) and the Administrator/Chief Executive Officer/Governing Body President (Personnel Record 10) on 11/26/2024 confirmed that the Governing Body had not approved a QAPI Plan that documented the frequency and detail of information to be collected for an effective QAPI program. On the evening of 11/26/2024, the Governing Body held an impromptu meeting. The plan, which included defined data and a frequency of collection, was compiled and approved by the Governing Body. Upon reviewing the quality assessment and performance improvement (QAPI) program binder and materials and the only Governing Body meeting minutes provided, which were for October and November 2024, it revealed that the documentation lacked the evidence of the Governing Body approved a QAPI Plan to ensure the detail and frequency of the data collection to ensure a hospice-wide QAPI program. An interview and extensive conversation with the Governing Body Vice President (Personnel Record 7) and the Administrator/Chief Executive Officer/Governing Body President (Personnel Record 10) on 11/26/2024 confirmed that the Governing Body had not approved a QAPI Plan that documented the frequency and detail of information to be collected for an effective QAPI program. On the evening of 11/26/2024, the Governing Body held an impromptu meeting. The plan, which included defined data and a frequency of collection, was compiled and approved by the Governing Body.”

“It is required that the hospice takes action to improve performance, assesses the success of the action after implementing it, and tracks ongoing results to ensure improvement is sustained. This standard was not met as evidenced by document review and interview revealed upon reviewing the quality assessment and performance improvement (QAPI) program documents and binder, the documentation lacked evidence that hospice performance improvement activities were assessed for the successful outcomes expected from implementation of the improvement activities. There was no documentation, other than the performance improvement/plan of correction initial documentation to outline if the plan of correction was implemented, the post-implementation assessment, or any tracking of improvement sustained. There was no plan except an objection “ ... To conduct Performance Improvement Projects aimed at performance to ensure that it is sustained...” It was confirmed during an interview with the Alternate Administrator/Chief Executive Officer/ Governing Body President (Personnel Record 10) and the Governing Body Vice President/Human Relations (Personnel Record 7) on 11/26/2024 and 11/27/2024 that there was no documented assessment of the interventions implemented to improve the agency’s performance in the problem areas documented. Upon reviewing the quality assessment and performance improvement (QAPI) program documents and binder, the documentation lacked evidence that hospice performance improvement activities were assessed for the successful outcomes expected from implementation of the improvement activities. There was no documentation, other than the performance improvement/plan of correction initial documentation to outline if the plan of correction was implemented, the post-implementation assessment, or any tracking of improvement sustained. There was no plan except an objection “ ... To conduct Performance Improvement Projects aimed at performance to ensure that it is sustained...” It was confirmed during an interview with the Alternate Administrator/Chief Executive Officer/ Governing Body President (Personnel Record 10) and the Governing Body Vice President/Human Relations (Personnel Record 7) on 11/26/2024 and 11/27/2024 that there was no documented assessment of the interventions implemented to improve the agency’s performance in the problem areas documented.”

“It is required that one or more individual(s) is appointed by the governing body as responsible for operating the QAPI program. This standard was not met as evidenced by document review and interview revealed upon review of the Governing Body Meeting Minutes from 10/24/2024 and 11/20/2024 that the documentation lacked evidence that an individual had been appointed by the Governing Body to be responsible for the operation and oversight of the QAPI program. During an interview with the Alternate Administrator/CEO/Governing Body President (Personnel Record 10) and the Governing Body Vice President/Human Relations (Personnel Record 7), it was confirmed that no individual had been appointed to spearhead the QAPI program. On the evening of 11/26/2024, during the site visit, the Governing Body held a meeting. The plan, which included defined data and a frequency of collection, was compiled and approved by the Governing Body. Upon review of the Governing Body Meeting Minutes from 10/24/2024 and 11/20/2024, it was revealed that the documentation lacked evidence that an individual had been appointed by the Governing Body to be responsible for the operation and oversight of the QAPI program. During an interview with the Alternate Administrator/CEO/Governing Body President (Personnel Record 10) and the Governing Body Vice President/Human Relations (Personnel Record 7), it was confirmed that no individual had been appointed to spearhead the QAPI program. On the evening of 11/26/2024, the Governing Body held an impromptu meeting and appointed the Director of Nursing to be responsible for the QAPI program.”

“It is required that hospice performance improvement (PI) activities involve licensed professionals as participants. This standard was not met as evidenced by document review and interview upon reviewing the quality assessment and performance improvement (QAPI) program, the documentation lacked evidence that hospice performance improvement activities were conducted and involved licensed professionals as participants. Only one QAPI meeting, on 11/13/2024, was documented for 2024, and the only signatures included were the Administrator and the CEO/Alternate Administrator on the meeting sign-in sheet at the time of review. No other disciplines were documented as having been included. It was confirmed during an interview with the Alternate Administrator/Chief Executive Officer/ Governing Body President (Personnel Record 10) and the Governing Body Vice President/Human Relations (Personnel Record 7) on 11/26/2024 and 11/27/2024 that there had been only one QAPI meeting and there was no documentation of the Medical Director, the Social Worker, or the Chaplain/Bereavement Coordinator’s involvement in the agency’s QAPI/Performance Improvement activities. Upon reviewing the quality assessment and performance improvement (QAPI) program, the documentation lacked evidence that hospice performance improvement activities were conducted and involved licensed professionals as participants. Only one QAPI meeting, on 11/13/2024, was documented for 2024, and the only signatures included were the Administrator and the CEO/Alternate Administrator on the meeting sign-in sheet at the time of review. No other disciplines were documented as having been included. It was confirmed during an interview with the Alternate Administrator/Chief Executive Officer/ Governing Body President (Personnel Record 10) and the Governing Body Vice President/Human Relations (Personnel Record 7) on 11/26/2024 and 11/27/2024 that there had been only one QAPI meeting and there was no documentation of the Medical Director, the Social Worker, or the Chaplain/Bereavement Coordinator’s involvement in the agency’s QAPI/Performance Improvement activities.”

“It is required that bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100 %) of patients that died under hospice care revealed the agency did not ensure bereavement services were provided. Clinical Record 7: The patient, who lived at home, elected the hospice benefit on 05/08/2024 and died on 05/09/2024 with the diagnosis of malignant neoplasm of the lung. No bereavement activity was documented following the patient’s death on hospice services. During an interview on 11/26/2024 with the Vice President of the Governing Body/Human Relations (VPGB/HR) (Personnel Record 7) and the Alternate Administrator/Chief Executive Director/Governing Body President (AA/CEO/GB President) (Personnel Record 10), it was confirmed that no documentation in the clinical record or the Bereavement binder could be provided to show any post-death bereavement activities/interventions and the current staff was not involved with the care of this discharged patient.”

“It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 5 (20%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure that the hospice aide documented all interventions in the care plan. Document 1: Hospice Aide Services (Policy No. 9-020) October 2019 “...Hospice aides will document care provided in accordance with the hospice aide assignment...” Clinical Record 4: The patient elected the hospice benefit on 02/06/2024 and was administratively discharged on 06/11/2024. A review revealed no documented discipline orders, but there were aide visits documented twice weekly. The Hospice Aide Care Plan dated 02/06/2024 assigned the hospice aide interventions to shower, shampoo hair, comb hair, mouth care, clean nails, perineal care, and moisturize skin every visit. The aide visit notes dated 03/07/2024, 03/11/2024, 03/14/2024, 03/18/2024, 03/21/2024, 03/25/2024, and 03/28/2024 documented a shower was completed. There was no documentation that the aide completed the assigned tasks of shampooing hair, combing hair, mouth care, cleaning nails, perineal care, and moisturizing skin. Additionally, the aide did not document a reason for not completing the tasks. During an interview on 11/26/2024 with the Vice President of the Governing Body/Human Relations (VPGB/HR) (Personnel Record 7) and the Alternate Administrator/Chief Executive Director/Governing Body President (AA/CEO/GB President) (Personnel Record 10), it was confirmed that no further documentation could be provided, and the current staff was not involved with the care of this discharged patient.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 5 (20%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure that the hospice aide notified the registered nurse that all interventions in the care plan were not performed. Document 1: Hospice Aide Services (Policy No. 9-020) October 2019 “...Hospice aides will document care provided in accordance with the hospice aide assignment. Hospice aides must report ... changes related to the plan of care ...” Clinical Record 4: The patient elected the hospice benefit on 02/06/2024 and was administratively discharged on 06/11/2024. The plans of care for 02/06/2024 to 05/05/2024 and 05/06/2024 to 08/03/2024 included orders for the hospice aide to perform visits twice a week. The Hospice Aide Care Plan dated 02/06/2024 assigned the hospice aide interventions to shower, shampoo hair, comb hair, mouth care, clean nails, perineal care, and moisturize skin every visit. The aide visit notes dated 03/07/2024, 03/11/2024, 03/14/2024, 03/18/2024, 03/21/2024, 03/25/2024, and 03/28/2024 documented a shower was completed. There was no documentation that the aide completed the assigned tasks of shampooing hair, combing hair, mouth care, cleaning nails, perineal care, and moisturizing skin. Additionally, the aide did not document a reason for not completing the task or note that the Registered Nurse was notified. During an interview on 11/26/2024 with the Vice President of the Governing Body/Human Relations (VPGB/HR) (Personnel Record 7) and the Alternate Administrator/Chief Executive Director/Governing Body President (AA/CEO/GB President) (Personnel Record 10), it was confirmed that no further documentation could be provided and the current staff was not involved with the care of this discharged patient.”

“It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient’s life expectancy is six months or less if the illness runs its normal course. This standard was not met as evidenced by clinical record review and interview. In 1 of 7 (14%) clinical records reviewed revealed the agency did not ensure that an initial physician certification of terminal illness was documented in the patient’s clinical record. Clinical Record 6: The patient elected hospice care on 02/06/2024 and revoked hospice services on 03/04/2024. A review of the clinical record revealed no evidence of a documented initial certification of terminal illness. The plan of care for 02/06/2024 to 5/05/2024 had a space for the hospice physician’s written certification, and the space was blank. During an interview on 11/26/2024 with the Governing Body Vice President and Director of Human Relations (Personnel Record 7) and the Alternate Administrator/Chief Executive Officer/Governing Body President (Personnel Record 10), the finding was confirmed, and no additional documentation was provided. The patients were all admitted and discharged prior to the current leadership assuming control of the agency on 10/20/2024.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. Each patient’s record includes signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review and interview. In 2 of 7 (29%) clinical records reviewed revealed that the agency did not ensure that the patient’s record contained signed copies of the notice of patient rights and the hospice election statement Clinical Record 6: The patient elected hospice care on 02/06/2024. A clinical record review revealed that there was no signed confirmation that the patient received the Notice of Patient Rights and the Hospice Election of Benefits Statement. Clinical Record 7: The patient elected hospice care on 05/08/2024. A clinical record review revealed no documentation on the effective date of the Hospice Election Statement, the date the consents were signed, or the hospice representative’s signature. During an interview with the Governing Body Vice President/Director of Human Relations (Personnel Record 7) confirmed the missing documentation. These patients were part of the active patients prior to the current staff officially taking over the agency on 10/20/2024.”

“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. This standard was not met as evidenced by clinical record review and interview. In 1 of 7 (14%) clinical records reviewed revealed the agency did not ensure that there was a documented physician recertification of terminal illness in the clinical record. Clinical Record 4: The patient elected hospice care on 02/06/2024 and was administratively discharged on 06/11/2024. A clinical record review revealed no documented evidence that a recertification of the terminal illness was completed by the physician for the second benefit period 05/06/2024 to 08/03/2024. During an interview on 11/26/2024 with the Governing Body Vice President and Director of Human Relations (Personnel Record 7) and the Alternate Administrator/Chief Executive Officer/Governing Body President (Personnel Record 10), the finding was confirmed, and no additional documentation was provided. The patients were all admitted and discharged prior to the current leadership assuming control of the agency on 10/20/2024.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 3 (100%) clinical records reviewed in which there was a live discharge revealed the agency did not ensure that the patient’s discharge summary was sent to the patient’s attending physician. Document 1: Discharge From Hospice Program (Policy No. 1-025) October 2019 “... A copy of the discharge summary will be sent to the attending physician...” Clinical Record 4: The patient elected the hospice benefit on 02/06/2024 and was administratively discharged on 06/11/2024. A clinical record review revealed that no discharge summary was forwarded to the patient’s attending upon discharge from the hospice agency. Clinical Record 5: The patient elected the hospice benefit on 04/02/2024 and was administratively discharged on 06/11/2024. A clinical record review revealed that no discharge summary was forwarded to the patient’s attending upon discharge from the hospice agency. Clinical Record 6: The patient elected the hospice benefit on 02/06/2024 and revoked the benefit on 03/04/2024. A clinical record review revealed that no discharge summary was forwarded to the patient’s attending upon discharge from the hospice agency. It was confirmed during an interview on 11/26/2024 with the Governing Body Vice President and Director of Human Relations (Personnel Record 7) and the Alternate Administrator/Chief Executive Officer/Governing Body President (Personnel Record 10) that no discharge summaries were documented, and nothing was forwarded to the patient’s attending physician upon discharge from the agency. There was no documentation that any clinical information was forwarded. These patients were all discharged prior to the current leadership assuming their roles on 10/20/2024.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, and the patient’s latest physician orders. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 3 (100%) clinical records reviewed in which there was a live discharge revealed the agency did not ensure that a discharge summary was documented for the patient. Document 1: Discharge Summary (Policy No. 1-026) October 2019 “...The discharge summary ... will be completed and submitted within 72 hours of discharge from service..” Clinical Record 4: The patient elected the hospice benefit on 02/06/2024 and was administratively discharged on 06/11/2024. A review of the clinical record revealed no documented discharge summary. Clinical Record 5: The patient elected the hospice benefit on 04/02/2024 and was administratively discharged on 06/11/2024. A review of the clinical record revealed no documented discharge summary. Clinical Record 6: The patient elected the hospice benefit on 02/06/2024 and revoked the benefit on 03/04/2024. A review of the clinical record revealed no documented discharge summary. During an interview on 11/26/2024 with the Governing Body Vice President and Director of Human Relations (Personnel Record 7) and the Alternate Administrator/Chief Executive Officer/Governing Body President (Personnel Record 10), confirmed the absence of discharge summaries documented for the clinical records listed in the evidence. The patients were all discharged prior to the current leadership assuming control of the agency on 10/20/2024.”

“It is required that the hospice maintains a written comprehensive emergency preparedness program that demonstrates compliance with applicable federal, state, and local emergency preparedness requirements, uses an “all hazards” approach, describes the hospice’s approach to meeting the health, safety, and security of the staff, the patient population, with attention to their mobility, [and] describes how the hospice coordinates with other healthcare facilities, as well as the community, during an emergency or disaster situation. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This standard was not met as evidenced by document review and interviews with the Alternate Administrator/ Alternate Director of Nursing/Volunteer Coordinator, which revealed that the governing body failed to ensure the agency implemented the emergency preparedness program and emergency preparedness (EP) plan in the following areas: Failed to ensure that the EP plan was reviewed and updated at least every two (2) years [HSEP.2. D/E4]; Failed to develop and implement an EP plan that was based on a hospice-based and community-based risk assessment, using an “all-hazards” approach [HSEP.2.D/E6]; Failed to ensure that policies and procedures, based on the emergency plan, the risk assessment, and the communication plan, were reviewed and updated at least every two (2) years [HSEP.3.D/E13]; Failed to ensure that the emergency preparedness training and testing program was reviewed and updated at least every two (2) years [HSEP.5. D/E36]; Failed to ensure that emergency preparedness training was completed by staff at the time of hire and annually per the agency’s policy [HSEP.5.D/E37]; and Failed to ensure that the agency conducted exercises to test the EP plan at least annually [HSEP.6.I/E39]. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.113: Emergency Preparedness. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that the hospice develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI). The hospice governing body is responsible for ensuring that the program: reflects the complexity of the hospice and services; involves all hospice services, including those provided under contract; addresses efforts and sets priorities for improved quality of care and patient safety, and ensures all improvement actions are evaluated for effectiveness; focuses on indicators related to improved palliative outcomes; includes investigation and analysis of sentinel and adverse events; includes defined data detail and frequency of collection, and approves such; has evidence of action taken that results in improvement in hospice performance; and, is evaluated annually. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of Participation was not met as evidenced by document review, Quality Assessment and Performance Improvement (QAPI) documents, and interviews with the the Alternate Administrator/ Alternate Director of Nursing/Volunteer Coordinator, which revealed that the governing body failed to implement the QAPI program in the following areas: Failed to maintain a coordinated, agency-wide program for infection surveillance and the identification, prevention, control and investigation of infectious and communicable diseases [HQPI.6.I/L580]; Failed to measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance to enable the hospice to assess processes of care, hospice services, and operations [HQPI.4.I/L562]; Failed to use patient care and other relevant data in the design of the agency QAPI program [HQPI.5.I/L563]; Failed to ensure the frequency and detail of the data collection was approved by the hospice’s governing body [HQPI.5.I/L565]; Failed to ensure that performance improvement activities focus on high-risk, high-volume, or problem-prone areas [HQPI.6.I/L566]; Failed to ensure that hospice performance improvement (PI) activities involved licensed professionals as participants [HQPI.6.I/L586]; and Failed to ensure that performance improvement activities tracked adverse patient events, analyzed the causes, and implemented preventive action and mechanisms [HQPI.7.I/L569]. The cumulative effect of these deficiencies has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR: 418.58 Quality assessment and performance improvement. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.”

“It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. This standard was not met as evidenced by document review and interview. The agency did not ensure that the EP plan was reviewed and updated at least every two (2) years. A review of the EP plan revealed the plan was dated October 2019. There was no evidence that the EP plan was reviewed and updated as of 06/06/2024. During an interview on 06/06/2024, the Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator confirmed that the EP plan was not reviewed and updated at least every two (2) years. The Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator contacted the owners to obtain Emergency Preparedness records without results. No further documentation was provided as of the conclusion of the site review. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence of the emergency plan reviewed for 2021, 2022, 2023, and 2024.”

“It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. The plan: Is based on and includes a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served; Includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of: a) Power failures; b) Natural or man-made disasters; c) Emerging infectious diseases (EIDS) that place the health and safety of patients and employees at risk; and d) Other anticipated emergencies that could affect the hospice’s ability to provide care. This standard was not met as evidenced by document review and interview. Review of the emergency preparedness binder revealed no documented evidence that the EP plan was based on and included a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served. The hospice did not ensure an all-hazards vulnerability analysis was completed and documented for 2023 and 2024 as of 06/06/2024. During an interview on 06/06/2024, the Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator confirmed that a documented hospice-based and community-based risk assessment was not completed every two years using an “all-hazards” approach specific to the geography and population served. The Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator contacted the owners to obtain Emergency Preparedness records without results. No further documentation was provided. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence of a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served for the years 2021, 2022, 2023, and 2024.”

“It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. Policies and procedures are reviewed and updated at least every two (2) years. This standard was not met as evidenced by document review and interview. The agency did not ensure that EP policies and procedures were reviewed and updated at least every two (2) years. The EP policies and procedures reviewed were dated 10/2019. A review of the EP policies and procedures revealed the policies were not reviewed and updated as of 06/06/2024. During an interview on 06/06/2024, the Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator confirmed that the EP policies and procedures, based on the emergency plan, the risk assessment, and the communication plan were not reviewed and updated at least every two (2) years. The Alternate Administrator/Alternate Director of Nursing/ Volunteer Coordinator contacted the owners to obtain Emergency Preparedness records without results. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence that the emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan were reviewed and updated at least every two (2) years.”

“It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. This standard was not met as evidenced by document review and interview. Agency Policy, “Emergency Management Plan Policy No. 4-001”, dated October 2019, stated in part, “The training and testing program is reviewed and updated at least annually. The training includes initial training in emergency preparedness policies and procedures and their assigned emergency response roles to all new and existing staff, individuals providing service under arrangement, and volunteers, if applicable. The training is provided annually and demonstrates staff knowledge of emergency procedures. The agency will test the emergency management plan at each site included in the plan at least annually, either in response to an actual emergency or in a planned exercise.” Upon reviewing the emergency preparedness (EP) plan and the emergency preparedness training program, the agency did not ensure that the training program was based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. There was no documented risk assessment for 2023 and 2024. The agency’s emergency preparedness plan was dated October, 2019. The documentation lacked evidence that the training program had been reviewed and updated. During an interview on 06/06/2024, the Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator confirmed that a documented emergency preparedness training program was not based on a current risk assessment and was not reviewed and updated at least every two (2) years. The Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator contacted the owners to obtain Emergency Preparedness records without results. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence that the training program was based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The document lacked evidence of a risk assessment for the years 2021, 2022, 2023, and 2024. The documentation lacked evidence that the training program was updated for 2021, 2022, 2023, and 2024.”

“It is required that the hospice EP training program includes the following: for all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles; demonstration of staff knowledge of emergency procedures; EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years; a) more frequent training occurs if there is a significant update of EP policies and procedures; a periodic review and rehearsal of the hospice’s EP plan with hospice employees (including non-employee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others; and documentation of each training including the date(s), participants, and content. This standard was not met as evidenced by personnel record review, document review, and interview. Agency policy, “Emergency Management Plan” #4-001” (dated October 2019) stated in part, “The training and testing program is reviewed and updated at least annually. The training includes initial training in emergency preparedness policies and procedures and their assigned emergency response roles to all new and existing staff, individuals providing service under arrangement, and volunteers, if applicable. The training is provided annually and demonstrates staff knowledge of emergency procedures. The agency will test the emergency management plan at each site included in the plan at least annually, either in response to an actual emergency or in a planned exercise.” In 4 of 7 (57%) personnel records reviewed, the organization did not ensure that emergency preparedness training was completed at the time of hire and annually per the agency’s policy. Personnel Record 1: The Administrator/Director of Nursing was hired on 11/04/2021. A review of the personnel record revealed no documented evidence of emergency preparedness training annually for 2023 and 2024. Personnel Record 2: The Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator was hired on 11/10/2021. A review of the personnel record revealed no documented evidence of emergency preparedness training annually for 2023 and 2024. Personnel Record 6: The Social Worker was hired on 11/06/2021. A review of the personnel record revealed no documented evidence of emergency preparedness training annually for 2023 and 2024. Personnel Record 7: The Chaplain/Bereavement Coordinator was hired on 11/04/2021. A review of the personnel record revealed no documented evidence of emergency preparedness training annually for 2023 and 2024. During an interview on 06/06/2024, the Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator confirmed the finding. The Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator contacted the owners to obtain Emergency Preparedness records without results.”

“It is required that testing: The hospice providing care in the patient’s home conducts exercises to test the emergency preparedness plan annually, including participation in a full-scale exercise that is community-based every two (2) years. When a community-based exercise is not accessible, testing includes participation in an individual, facility-based functional exercise every two (2) years. If the organization experiences a natural or man-made emergency that requires activation of the emergency plan, the organization is exempt from engaging in its next required full-scale community-based exercise or individual, facility-based functional exercise following the onset of the emergency event. Conducting an additional exercise every two (2) years – opposite the year that a full-scale exercise or functional exercise is conducted. This exercise may include, but is not limited to, a second full-scale exercise that is community-based or a facility-based functional exercise, or a mock disaster drill, or a tabletop exercise or workshop that is led by a facilitator that includes a group discussion using a narrated, clinically relevant emergency scenario and a set of problem statements, directed messages, or prepared questions designed to challenge the emergency plan. This standard was not met as evidenced by document review and interview. A review of the Emergency Preparedness (EP) binder revealed that the agency did not ensure that exercises were completed to test the emergency preparedness plan. The Emergency Preparedness (EP) documents included an EP plan and hazard risk assessment dated October, 2019. The EP binder did not include documentation demonstrating that the agency participated in exercises to test the emergency preparedness as of 06/06/2024. During an interview on 06/06/2024, the Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator confirmed that the emergency preparedness plan was not tested in 2023 or 2024 to date. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence that the emergency preparedness plan was tested annually, including participation in a full-scale exercise that is community-based every two (2) years and conducting an additional exercise every two (2) years – opposite the year that a full-scale exercise or functional exercise is conducted.”

“It is required that the hospice provides information on advance directives upon initiation of hospice care. Whether or not the patient has executed an advance directive is documented in a prominent part of the patient’s record. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed, the agency did not ensure that the patient received information regarding advanced directives upon initiation of hospice care. Clinical Record 4: The patient elected hospice care on 02/06/2024. A review of the clinical record revealed no evidence that the patient received written information on advance directives upon initiation of hospice care. Clinical Record 5: The patient elected hospice care on 05/08/2024. A review of the clinical record revealed no evidence that the patient received written information on advance directives upon initiation of hospice care. During a joint record review and interview on 06/07/2024, the Alternate Administrator/Director of Nursing/Volunteer Coordinator confirmed that the record lacked evidence that the patient received information regarding advanced directives upon initiation of hospice care.”

“It is required that during the initial assessment visit and in advance of providing care the hospice provides the patient—or his or her representative—with verbal (meaning spoken) and written notice of the patient’s rights and responsibilities. This information is provided in a language and manner that the patient understands. The hospice obtains the patient’s or representative’s signature confirming that he or she received a copy of the Bill of Rights and Responsibilities statement. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed, the agency did not ensure that the patient or representative received notice of the patient’s rights and responsibilities. Clinical Record 4: The patient’s date of election was 02/06/2024. The record lacked evidence of the patient or representative receiving a copy of the Bill of Rights. Clinical Record 5: The patient’s date of election was 05/09/2024. The record lacked evidence of the patient or representative receiving a copy of the Bill of Rights. During a joint record review and interview on 06/07/2024, the Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator confirmed that the records lacked evidence that the patient or representative received notice of the patient’s rights and responsibilities.”

“It is required that the hospice registered nurse completes an initial assessment within 48 hours of the patient’s election of hospice care, in accordance with CMS §418.24 (the elements of the hospice care election statement). The physician, patient, or representative may request that the initial hospice assessment be completed in less than 48 hours. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed, the agency did not ensure that the initial hospice assessment was completed within 48 hours of the patient’s election of hospice care. Clinical Record 2: The patient elected hospice care on 02/06/2024. A review of the clinical record revealed an initial comprehensive assessment partially completed by the Registered Nurse (RN) dated 02/06/2024. There was no evidence that the RN completed the initial comprehensive assessment. Clinical Record 4: The patient elected hospice care on 02/06/2024. A review of the clinical record revealed an initial comprehensive assessment partially completed by the Registered Nurse (RN) dated 02/06/2024. There was no evidence that the RN completed the initial comprehensive assessment. During a joint record review and interview on 06/07/2024, the Administrator/Director of Nursing confirmed that the initial hospice assessment was not completed in less than 48 hours of the patient’s election of hospice care.”

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed, the agency did not ensure that the hospice Interdisciplinary Group (IDG) completed an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. Clinical Record 2: The patient elected hospice care on 02/06/2024. A review of the clinical record revealed an initial comprehensive assessment partially completed by the Registered Nurse (RN) dated 02/06/2024. There was no evidence that the RN completed the initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. Clinical Record 4: The patient elected hospice care on 02/06/2024. A review of the clinical record revealed an initial comprehensive assessment partially completed by the Registered Nurse (RN) dated 02/06/2024. In addition, the Social Worker (SW) initial assessment was partially completed on 02/08/2024. There was no evidence that the RN and SW completed the initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. During a joint record review and interview on 06/07/2024, the Administrator/Director of Nursing confirmed that the initial comprehensive assessment was not completed no later than five calendar days after the election of hospice care.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following, the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 5 (20%) clinical records reviewed and home visits observed, the agency did not ensure that the comprehensive assessment included a review of the patient’s current medications. Clinical Record 2/Home Visit 1: The patient elected hospice care on 02/06/2024 and resided in a group home. During the home visit with the Hospice Aide (HA) [Personnel Record 5] on 06/06/2024, a review of the patient’s medication bottles revealed that the patient was taking Memantine HCl 5mg, one tablet daily started 10/10/2023, last filled on 04/11/2024; Quetiapine Fumarate 100mg, one tablet at bedtime started 09/14/2023 last filled on 04/12/2024; Quetiapine Fumarate 50mg one tablet in the morning started on 09/13/2023; and Trazadone 50mg 1 1/2 tablets at bedtime started 10/10/2023 and, last filled on 04/11/2023. The hospice medication profile dated 06/06/2024 documented Quetiapine 25mg, one tablet at bedtime, and Trazadone 40mg, one tablet at bedtime. The caregiver at the group home who administers the medications stated that the patient was taking the medications as ordered on the bottles. The medication profile did not document Memantine HCl and the correct dosage and frequency of administration for the Quetiapine and Trazadone. There was no evidence that Memantine HCl was reviewed with the patient’s medication regimen. During a joint record review and interview on 06/07/2024, the Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator confirmed that there was no documented evidence the medications were reconciled at the time of each comprehensive assessment and updated to the drug profile.”

“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. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any), the patient or patient representative, and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 3 of 5 (60%) clinical records reviewed, the agency did not ensure the spiritual counseling services were provided per the plan of care. Clinical Record 1: The patient elected hospice care 04/02/2024. The plan of care dated 04/02/2024 through 06/30/2024 ordered spiritual care visits one time a month. A review of the clinical record revealed no documented spiritual care visits for April and May. There was no evidence of documented missed visits or communication with the patient or physician. Clinical Record 2: The patient elected hospice care 02/06/2024. The plans of care dated 02/06/2024 through 05/05/2024 and 05/06/2024 through 08/03/2024 ordered spiritual care visits one time a month. A review of the clinical record revealed no documented spiritual care visits for March, April, and May. There was no evidence of documented missed visits or communication with the patient or physician. Clinical Record 3: The patient’s date of election was 02/06/2024. The plans of care dated 02/06/2024 through 05/05/2024 and 05/06/2024 through 08/03/2024 ordered spiritual care visits one time a month. A review of the clinical record revealed no documented spiritual care visits for March, April, and May. There was no evidence of documented missed visits or communication with the patient or physician. During a joint review of the record and an interview on 06/07/2024, the Administrator/Director of Nursing confirmed that the records lacked evidence of missed visits.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals, 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 and interview. In 2 of 5 (40%) clinical records reviewed, the agency did not ensure that the plan of care (POC) included planned interventions and goals based on problems identified in the comprehensive assessments. Clinical Record 1: The patient elected hospice care on 04/02/2024 with the primary hospice diagnosis of senile degeneration of the brain. The initial comprehensive assessment completed by the Registered Nurse (RN) on 04/02/2024 documented that the patient had memory loss, a pacemaker, received insulin, and used a glucometer. The initial Social Worker assessment dated 04/04/2024 documented that the patient had no funeral plans. The plan of care dated 04/02/2024 through 06/30/2024 did not document problems, interventions, and goals related to the patient’s memory loss, pacemaker, insulin dependence, glucometer management, and funeral planning. Clinical Record 4: The patient elected hospice care on 02/06/2024 with the primary diagnosis of atherosclerotic heart disease of the native coronary artery without angina pectoris. The RN comprehensive assessment dated 02/13/2024 documented that the patient had edema to the lower extremities, fatigued easily, had bladder incontinence, and impaired mobility. The plan of care dated 02/06/2024 through 05/05/2024 did not document problems, interventions, and goals for edema, fatigue, bladder incontinence, and impaired mobility. During a joint review of the records and an interview on 06/07/2024, the Administrator/Director of Nursing confirmed that there was no documented evidence that the plans of care included problems, goals, and interventions for the problems identified in the assessments.”

“It is required that the hospice measures, analyzes, and tracks quality indicators of performance that enable the assessment of processes of care, hospice services, operations, and adverse patient events. This standard was not met as evidenced by document review and interview. A review of the quality assessment and performance improvement (QAPI) program and administrative documents revealed documentation lacked evidence that the agency measured, analyzed, and tracked quality indicators of performance that enabled the assessment of processes of care, hospice services, operations, and adverse patient events. During an interview on 06/07/2024, the Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator confirmed that the QAPI program lacked evidence that the agency measured, analyzed, and tracked quality indicators of performance that enable the assessment of processes of care, hospice services, operations, and adverse patient events. The Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator stated that the QAPI program was not part of her contract with the agency owners and that the owners were responsible. The Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator contacted the owners to obtain QAPI records without results. Upon reviewing the quality assessment and performance improvement (QAPI) program, the documentation lacked evidence that the agency measured, analyzed, and tracked quality indicators of performance that enable the assessment of processes of care, hospice services, operations, and adverse patient events.”

“It is required that the hospice uses quality indicator data, including patient care data and other relevant data, in the QAPI program. This standard was not met as evidenced by document review and interview. A review of the quality assessment and performance improvement (QAPI) program and administrative documents revealed documentation lacked evidence that the agency used quality indicator data, including patient care, and other relevant data, in the design of the program. During an interview on 06/07/2024, the Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator confirmed that the QAPI program lacked evidence that the agency used quality indicator data, including patient care, and other relevant data, in the design of the program. The Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator stated that the QAPI program was not part of her contract with the agency owners and that the owners were responsible. The Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator contacted the owners to obtain QAPI records without results. Upon reviewing the quality assessment and performance improvement (QAPI) program, the documentation lacked evidence that the agency used quality indicator data, including patient care, and other relevant data, in the design of the program. The program lacked documentation of the COVID-19 Public Health Emergency from 03/01/2020-05/11/2023.”

“It is required that the hospice uses quality indicator data, including patient care data and other relevant data, in the QAPI program. Data elements abstracted and aggregated from comprehensive patient assessments are used in quality assessment and improvement. Data collected is used to monitor the effectiveness and safety of services and quality of care and identify opportunities and priorities for improvement. The frequency and detail of the data collection is approved by the hospice’s governance. This standard was not met as evidenced by document review and interview. Upon reviewing the quality assessment and performance improvement (QAPI) program, the documentation lacked evidence that the hospice’s governing board approved the frequency and detail of the data collection. During an interview on 06/07/2024, the Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator confirmed that the QAPI program lacked evidence that the hospice’s governing board approved the frequency and detail of the data collection. The Alternate Administrator/Alternate Director of Nursing/ Volunteer Coordinator stated that the QAPI program was not part of her contract with the agency owners and that the owners were responsible. The Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator contacted the owners to obtain QAPI records without results. Upon reviewing the quality assessment and performance improvement (QAPI) program, the documentation lacked evidence that the hospice’s governing board approved the frequency and detail of the data collection.”

“It is required that hospice performance improvement (PI) activities focus on high-risk, high-volume, or problem-prone areas. This standard was not met as evidenced by document review and interview. Upon reviewing the quality assessment and performance improvement (QAPI) program, the documentation lacked evidence that hospice performance improvement activities focused on high-risk, high-volume, or problem-prone areas. During an interview on 06/07/2024, the Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator confirmed that the QAPI program lacked evidence that hospice performance improvement activities focused on high-risk, high-volume, or problem-prone areas. The Alternate Administrator/ Alternate Director of Nursing/Volunteer Coordinator stated that the QAPI program was not part of her contract with the agency owners and that the owners were responsible. The Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator contacted the owners to obtain QAPI records without results. Upon reviewing the quality assessment and performance improvement (QAPI) program, the documentation lacked evidence that hospice performance improvement activities focused on high-risk, high-volume, or problem-prone areas. The program lacked documentation of the COVID-19 Public Health Emergency from 03/01/2020-05/11/2023.”

“It is required that performance improvement activities track adverse patient events, analyze the causes, and implement preventive action and mechanisms that include feedback and learning throughout the hospice. This standard was not met as evidenced by document review and interview. Upon reviewing the quality assessment and performance improvement (QAPI) program, the documentation lacked evidence that the performance improvement activities tracked adverse patient events, analyzed the causes, and implemented preventive action and mechanisms that included feedback and learning throughout the hospice. During an interview on 06/07/2024, the Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator confirmed that the QAPI program lacked evidence that the performance improvement activities tracked adverse patient events, analyzed the causes, and implemented preventive action and mechanisms that included feedback and learning throughout the hospice. The Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator stated that the QAPI program was not part of her contract with the agency owners and that the owners were responsible. The Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator contacted the owners to obtain QAPI records without results. Upon reviewing the quality assessment and performance improvement (QAPI) program, the documentation lacked evidence that the performance improvement activities tracked adverse patient events, analyzed the causes, and implemented preventive action and mechanisms that included feedback and learning throughout the hospice. The program lacked documentation of the COVID-19 Public Health Emergency from 03/01/2020-05/11/2023.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: hand hygiene. This standard was not met as evidenced by document review, interview and observation. Agency policy #7-009 “Hand Hygiene Policy Number “ stated in part, “Hand Washing with Soap and Water: Equipment: Paper towels and liquid soap; if water and liquid soap are not available, waterless hand washing products will be used. Wet hands and apply the soap, and rub hands together vigorously; avoid use of hot water because repeated exposure to hot water may increase risk of dermatitis. Wash hands for at least 20 seconds covering all surfaces of the hands and fingers. Rinse with warm water and dry the hands with a disposable towel from the fingers toward the forearm. Use a dry disposable towel to turn off faucet.” In 1 of 3 (33%) home visits observed, the agency did not ensure the staff followed the hand hygiene policy. Home Visit 1/Clinical Record 2: During the home visit with the Certified Nurse Aide [Personnel Record 5] (CNA) on 06/06/2024, the CNA washed their hands with soap and water, turned off the faucet with their arm, picked up their bag and the patient’s clothes, turned off the light, closed the bathroom door, and took the clothes to the laundry in the garage, all with wet hands. The CNA did not dry their hands and turn off the faucet with a disposable towel per the agency policy. During an interview on 06/06/2024, the Administrator/Director of Nursing and the Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator confirmed that the staff did not follow the hand hygiene policy.”

“It is required that hospice performance improvement (PI) activities include the surveillance, identification, prevention, control, and investigation of infectious and communicable disease as included in the infection control program. This standard was not met as evidenced by document review and interview. Upon reviewing the quality assessment and performance improvement (QAPI) program, the documentation lacked evidence that hospice performance improvement activities included the surveillance, identification, prevention, control, and investigation of infectious and communicable disease as included in the infection control program. During an interview on 06/07/2024, the Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator confirmed that the QAPI program lacked evidence that hospice performance improvement activities included the surveillance, identification, prevention, control, and investigation of infectious and communicable disease as included in the infection control program. The Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator stated that the QAPI program was not part of her contract with the agency owners and that the owners were responsible. The Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator contacted the owners to obtain QAPI records without results. Upon reviewing the quality assessment and performance improvement (QAPI) program, the documentation lacked evidence that hospice performance improvement activities included the surveillance, identification, prevention, control, and investigation of infectious and communicable disease as included in the infection control program. The program lacked documentation of the COVID-19 Public Health Emergency from 03/01/2020-05/11/2023.”

“It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by document review, interview, and personnel record review. Agency policy #7-001 “Infection Control Plan Policy” stated in part, “New personnel will receive a copy of the standard precautions (see Standard Precautions Policy No. 7-007) in their orientation packet. Personnel will be provided training on the basics of transmission of pathogens to patients and personnel, bloodborne diseases, the use of standard precautions, infectious waste management, and other infection control procedures when their work activities, as indicated below, may result in an exposure to blood, other potentially infectious materials, or under circumstances in which differentiation between body fluid types is difficult or impossible. Infection control inservices will be scheduled no less than annually. Attendance will be mandatory and will be documented. Records of inservice attendance will be maintained in the personnel file.” In 4 of 7 (57%) personnel records reviewed, the agency did not ensure the staff received infection control education per the agency policy. Personnel Record 1: The Administrator/Director of Nursing was hired on 11/04/2021. The record lacked evidence of infection control training annually for 2023. Personnel Record 2: The Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator was hired on 11/10/2021. A review of the personnel record revealed no infection control training annually for 2023. Personnel Record 6: The Social Worker was hired on 11/06/2021. A review of the personnel record revealed no infection control training annually for 2023. Personnel Record 7: The Chaplain/Bereavement Coordinator was hired on 11/04/2021. A review of the personnel record revealed no infection control training annually for 2023. During a joint record review and interview on 06/07/2024, the Administrator/Director of Nursing confirmed that the records lacked evidence of infection control education as described in the Infection Control Plan Policy.”

“It is required that hospice performance improvement (PI) activities involve licensed professionals as participants. This standard was not met as evidenced by document review and interview. Upon reviewing the quality assessment and performance improvement (QAPI) program, the documentation lacked evidence that hospice performance improvement activities were conducted and involved licensed professionals as participants. No QAPI meeting minutes were presented for review. The Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator contacted the owners to obtain QAPI records without results. Upon reviewing the quality assessment and performance improvement (QAPI) program, the documentation lacked evidence that hospice performance improvement activities involved licensed professionals as participants. The program lacked documentation of the COVID-19 Public Health Emergency from 03/01/2020-05/11/2023.”

“It is required that a hospice aide provide services included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 3 (67%) clinical records reviewed of patients with Hospice Aide (HA) services reviewed, the agency did not ensure that a HA provide services included in the plan of care. Clinical Record 2: The Hospice Aide Care Plan dated 02/06/2024 assigned the HA the relevant tasks: shower, shampoo hair, comb hair, mouth care, clean nails, perineal care, and moisture skin. The HA visit notes dated 03/07/2024, 03/11/2024, 03/14/2024, 03/18/2024, 03/21/2024, 03/25/2024, and 03/28/2024 documented a shower was completed. There was no documentation that the HA completed the assigned tasks shampoo hair, comb hair, mouth care, clean nails, perineal care, and moisture skin. The HA did not document a reason for not completing the tasks. Clinical Record 3: The Hospice Aide Care Plan dated 02/06/2024 assigned the HA the relevant tasks: shower, shampoo hair, comb hair, mouth care, electric shave, clean nails, perineal care, change bed linens, and moisture skin. The HA visit notes dated 02/07/2024, 02/10/2024, 02/12/2024, 02/15/2024, 02/20/2024, 02/22/2024, 02/26/2024, 02/29/2024, 03/04/2024, 03/07/2024, 03/11/2024, 03/14/2024, 03/18/2024, 03/21/2024, 03/25/2024, 03/28/2024, 04/01/2024, 04/04/2024, 04/08/2024, 04/11/2024, 04/15/2024, 04/18/2024, 04/22/2024, 04/25/3034, 04/29/2024, and 05/02/2024 documented a shower and an electric shave was completed. There was no documentation that the HA completed the assigned tasks shampoo hair, comb hair, mouth care, clean nails, perineal care, change bed linens, and moisture skin. The HA did not document a reason for not completing the tasks. During a joint review of the record and an interview on 06/07/2024, the Administrator/Director of Nursing confirmed there that the HA did not provide services included in the plan of care.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 2 of 3 (67%) clinical records reviewed of patients with Hospice Aide (HA) services, the agency did not ensure that the HA notified the Registered Nurse (RN) of the changes in the patient’s plan of care. Clinical Record 2: The Hospice Aide Care Plan dated 02/06/2024 assigned the HA the relevant tasks: shower, shampoo hair, comb hair, mouth care, clean nails, perineal care, and moisture skin. The HA visit notes dated 03/07/2024, 03/11/2024, 03/14/2024, 03/18/2024, 03/21/2024, 03/25/2024, and 03/28/2024 documented the HA provided the patient with a shower. The other assigned tasks were not documented as completed. There was no evidence that the HA notified the RN of changes in the patient’s needs and changes to the care plan. Clinical Record 3: The Hospice Aide Care Plan dated 02/06/2024 assigned the HA the relevant tasks: shower, shampoo hair, comb hair, mouth care, electric shave, clean nails, perineal care, change bed linens, and moisture skin. The HA visit notes dated 02/07/2024, 02/10/2024, 02/12/2024, 02/15/2024, 02/20/2024, 02/22/2024, 02/26/2024, 02/29/2024, 03/04/2024, 03/07/2024, 03/11/2024, 03/14/2024, 03/18/2024, 03/21/2024, 03/25/2024, 03/28/2024, 04/01/2024, 04/04/2024, 04/08/2024, 04/11/2024, 04/15/2024, 04/18/2024, 04/22/2024, 04/25/3034, 04/29/2024, and 05/02/2024 documented the HA provided the patient with a shower and electric shave. The other assigned tasks were not documented as completed. There was no evidence that the HA notified the RN of changes in the patient’s needs and changes to the care plan. During a joint clinical record review and interview on 06/07/2024, the Administrator/Director of Nursing confirmed that the hospice aide documentation lacked notification to the RN of the changes in plan of care.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice documents the cost savings achieved through volunteers. Documentation includes the identification of each position that is occupied by a volunteer, the work time spent by volunteers occupying those positions, estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions noted in Item 1, and for the durations noted in Item 2. This standard was not met as evidenced by document review and interview. The hospice was unable to provide evidence of volunteer hours for day to day administrative and/or direct patient care services provided. Review of the agency’s volunteer program/binder revealed no documented evidence of the number of direct care staff hours, the volunteer percentage, and the cost savings the hospice would have incurred if paid employees occupied the positions from February 2024 to May 2024. During a joint review of the volunteer program records and interview on 06/07/2024, the Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator confirmed that the agency did not document the direct care staff hours, the volunteer percentage, and the cost savings from February 2024 to May 2024. Upon reviewing the volunteer program, the documentation lacked evidence of the number of direct care staff hours, the volunteer percentage, and the cost savings the hospice would have incurred if paid employees occupied the positions from February 2024 to May 2024.”

“It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient’s life expectancy is six months or less if the illness runs its normal course. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure that the hospice medical director or physician designee provided written certification of terminal illness. Clinical Record 4: The patient elected hospice care on 02/06/2024. A review of the clinical record revealed no evidence of a documented initial certification of terminal illness. The plan of care dated 02/06/2024 through 05/05/2024 had a space for the hospice physician’s written certification, the space was blank. During a joint record review and interview on 06/07/2024, the Administrator/Director of Nursing confirmed that the record lacked a written initial certification of terminal illness.”

“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 for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. 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 standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed, the agency did not ensure that the hospice medical director or physician-designee provided written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Clinical Record 2: The patient elected hospice care on 02/06/2024. A review of the clinical record revealed no documented evidence that a recertification of the terminal illness was completed for the second benefit period starting 05/06/2024. Clinical Record 3: The patient elected hospice care on 02/06/2024. A review of the clinical record revealed no documented evidence that a recertification of the terminal illness was completed for the second benefit period starting 05/06/2024. During a joint review of the record and an interview on 06/07/2024, the Administrator/Director of Nursing agreed there was no documented evidence that the recertification was completed.”

“It is required that each patient’s record includes, at a minimum: signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed, the agency did not ensure that the patient’s record contained signed copies of the notice of patient rights and the hospice election statement. Clinical Record 4: The patient elected hospice care on 02/06/2024. A review of the clinical record revealed no signed copy of the admission consent, including confirmation that the patient received the notice of patient rights and the hospice election statement. Clinical Record 5: The patient elected hospice care on 05/08/2024. The admission consent forms contained the patient’s signature, but they did not document a hospice representative’s signature, the date of hospice election, and the date that the consents were signed. During a joint record review and interview on 06/07/2024, the Alternate Administrator/Alternate Director of Nursing/Volunteer Coordinator confirmed that the records lacked completed admission consents.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record review of a patient discharged, the agency did not ensure that the discharge summary was forwarded to the patient’s attending physician. Clinical Record 4: The patient elected hospice care on 02/06/2024 and revoked the election of hospice care on 03/04/2024. A review of the clinical record revealed that a discharge summary was not forwarded to the patient’s attending physician. During a joint record review and interview on 06/07/2024, the Administrator/Director of Nursing confirmed that the record lacked evidence that the discharge summary was forwarded to the patient’s attending physician.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record review of a patient discharged, the agency did not ensure that a discharge summary was documented with the required information. Clinical Record 4: The patient elected hospice care on 02/06/2024 and revoked the election of hospice care on 03/04/2024. A review of the clinical record revealed no discharge summary was documented in the clinical record. There was no evidence that clinical information was forwarded for continuity of care. During a joint record review and interview on 06/07/2024, the Administrator/Director of Nursing confirmed that the record lacked evidence of a completed discharge summary.”