Serenity First LLC

“It is required that the hospice aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. Homemaker services must be provided by individuals who meet the personnel requirements specified in paragraph (j) of this section. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by a review of clinical records and interviews which revealed the hospice: Failed to ensure that Hospice aides are assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group. Written patient care instructions for a hospice aide must be prepared by a registered nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of this section {HCDT.15. I/L625}; Failed to ensure hospice aide provides services that are ordered by the interdisciplinary group {HCDT.16. I/L626}; Failed to ensure that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities {CDT.18. I/L628}; and Failed to ensure that a registered nurse make an on-site visit to the patient’s home, no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs {HSRM.25. I/L629}. 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 418.76: Hospice aide and homemaker services. 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 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 5 of 18 (28%) clinical records reviewed revealed that the agency did not ensure an initial comprehensive assessment was completed and documented within five (5) calendar days of the election of hospice care. Clinical Record 4: The patient elected hospice care on 10/07/2023, and comprehensive assessments from nursing and the chaplain were completed within five (5) calendar days of the election. The Medical Social Worker (MSW) documented a phone call attempt on 10/09/2023 with no answer, and a message was left requesting a return call. The next documented attempt to contact the patient and family was on 10/16/2023 (eight (8) days after the election) with success, and a visit was scheduled for 10/24/2023 (17 days after the election) per the daughter’s request. The clinical record did not contain evidence supporting additional attempts by the MSW to complete the psychosocial and emotional comprehensive assessment within 5 calendar days of the hospice election or documented evidence that the assessment was completed by the nurse or chaplain. Clinical Record 10: The patient elected hospice care on 06/25/2023, and comprehensive assessments were completed by the Registered Nurse (RN) on 06/05/2023 and the chaplain (CH) on 06/07/2023. A clinical note completed by the MSW on 06/15/2023 documented the psychosocial assessment had been deferred because the assigned MSW was on vacation. The clinical record did not contain documentation to support attempts made by another MSW to complete the required comprehensive assessment or documented evidence that the assessment was completed by the nurse or chaplain. Clinical Record 14: The patient elected hospice care on 04/07/2023, and comprehensive assessments were completed by the RN on 04/07/2023 and the CH on 04/11/2023. A clinical note completed by the MSW on 04/10/2023 documented a call was placed to the caregiver and a voicemail was left. The clinical record did not contain documentation to support any additional attempts by the MSW to complete the required comprehensive assessment or documented evidence that the assessment was completed by the nurse or chaplain. Clinical Record 17: The patient elected hospice care on 02/20/2023, and comprehensive assessments were completed by the RN on 02/20/2023 and the CH on 02/23/2023. A clinical note completed by the MSW on 02/20/2023 documented a call to the caregiver to explain services provided by the MSW; however, the clinical record did not contain documentation to support any additional attempts by the MSW to complete the required comprehensive assessment or documented evidence that the assessment was completed by the nurse or chaplain. Clinical Record 19: The patient elected hospice care and the initial nursing assessment was completed on 08/01/2023. A psychosocial assessment was completed by the MSW on 08/08/2023 (seven (7) days after the election), and a spiritual assessment was completed by the chaplain on 08/17/2023 (9 days after the election). The clinical record did not contain documentation to support any attempts by the MSW and CH to complete the required comprehensive assessment within five (5) days of electing hospice or documented evidence that the psychosocial and spiritual assessments were completed by the nurse. On 02/09/2024 joint clinical record reviews and interviews were conducted with the Chief Operating Officer, Clinical Director, Clinical Coordinator, and Quality Assurance nurse, who confirmed that the identified clinical records did not contain evidence of completed comprehensive assessments within five (5) calendar days of the patient electing hospice services. The leadership team recognized that these late assessments were associated with a newer employee and began immediate reeducation and training with all staff.”

“It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by clinical record review and interview. In 8 of 14 (57%) clinical records reviewed, in which a Licensed Practical Nurse (LPN) supervisory visit was required, revealed that the agency did not ensure the Registered Nurse (RN) completed supervisory visits per the agency’s policy. Document 1: The policy titled, “Nursing Services, Policy Number PC. N15” (no date) stated in part, “the RN makes at least bi-monthly home visits (once every two weeks) and documents that the LPN/LVN is routinely providing nursing services in accordance with the patient’s plan of care and the LPN’s/LVN’s scope of practice.” Clinical Record 6: The LPN documented completed visits once a week from 12/07/2023 through 01/12/2024. The RN documented an LPN supervisory visit on 12/07/2023, and the next LPN supervisory visit was not documented until 01/12/2024 which was 36 days apart. Clinical Record 8: The LPN documented completed visits on 12/21/2023, 01/09/2024, 02/02/24, and 02/06/2024. The RN documented an LPN supervisory visit on 12/29/2023. The clinical record did not contain documented evidence of additional LPN supervisory visits. Clinical Record 10: The LPN documented five (5) completed visits between 12/6/2023 and 01/26/2024. The RN documented LPN supervisory visits on 12/03/2023, and the next LPN supervisory visit was not documented until 01/19/2024 which was 47 days apart. Clinical Record 13: The LPN documented completed visits weekly from 01/19/2024 through 02/04/2024. The RN documented LPN supervisory visits on 01/19/2024, and the next LPN supervisory visit was not documented until 02/04/2024 which was 16 days apart. Clinical Record 15: The LPN documented completed visits weekly from 08/24/2023 through 10/20/2023. The clinical record did not contain documented evidence supporting that the RN completed LPN supervisory visits once every 14 days per agency policy. Clinical Record 16: The LPN documented completed visits weekly from 06/08/2023 through 09/062023. The RN documented the first LPN supervisory visit on 08/03/2023 (56 days after the LPN began visiting), and the next LPN supervisory visit was documented on 08/06/2023. The clinical record did not contain documented evidence supporting that the RN completed LPN supervisory visits once every 14 days per agency policy. Clinical Record 18: The LPN documented completed visits once a week from 06/29/2023 through 07/21/2023 and 08/04/2023 through 08/18/2023. The clinical record did not contain any documentation supporting the fact that the RN completed LPN supervisory visits once every 14 days per agency policy. Clinical Record 19: The LPN documented completed visits once a week from 08/04/2023 through 09/29/2023. The RN documented LPN supervisory visits on 08/21/2023 17 days after the LPN began visiting), 08/28/2023, 08/31/2023, 09/04/2023, and 09/11/2023. The next LPN supervisory visit was not documented until 10/02/2023 which was 28 days apart. On 02/09/2023 joint document review, clinical record reviews, and interviews were conducted with the Chief Operating Officer, Clinical Director, Clinical Coordinator, and Quality Assurance Nurse, who all clarified that the agency’s policy PC. N15 regarding the supervision of LPN/LVN nursing services would be every two (2) weeks was defined by the agency as every 14 days. Leadership confirmed the clinical records identified did not include documentation to support the RN completing the LPN supervisory visits every 14 days. The Chief Operating Officer took immediate action with the EMR provider and had a hard stop added to require supervisory visits within a specific RN assessment. The team also confirmed the current policy did not include a date the policy was created, reviewed, and revised and verbalized understanding of instruction provided on including these dates.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a registered nurse who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, interview, and observation. In 3 of 18 (17%) clinical records reviewed, in which hospice aide services were accepted, revealed that the agency did not ensure the Registered Nurse (RN) provided specific written instructions for the aide to follow. Clinical Record 2: The hospice aide care plan, effective 08/01/2023, documented the tasks to transfer the client from bed/chair every visit as needed, transfer the client from chair/bed every visit as needed, and change linens weekly and as needed. The care plan did not provide the aide with specific frequencies on when to transfer the patient and change linens, forcing the aide to make decisions outside of the aide’s scope of practice. On 02/07/2024 a home visit and joint review of the facility’s treatment orders were conducted with the RN (Personnel Record 1), who confirmed a facility order to use the Hoyer lift when transferring the patient, and the patient was observed sitting up in a wheelchair with a Hoyer lift sling under her back and buttocks. The care plan did not alert the aide to the need for a transfer device and did not provide instructions on using the Hoyer lift when transferring the patient. Clinical Record 7: The hospice aide care plan effective on 09/27/2023 documented instructions to transfer the client from bed/chair and to transfer the client from the chair/bed every visit. The aide visit narrative on 02/05/2024 and 02/07/2024 documented that the patient required two (2) persons to transfer. The care plan did not alert the aide to the need for additional persons when transferring. Clinical Record 15: The initial nursing assessment was completed on 08/21/2023 and documented that the patient had a Percutaneous Endoscopic Gastrostomy (PEG) tube in place. The hospice aide care plan effective on 08/21/2023 did not alert the aide that the patient had the PEG tube or if the aide was to provide any site care. On 02/09/2023 joint clinical record reviews and interviews were conducted with the Chief Operating Officer, Clinical Director, Clinical Coordinator, and Quality Assurance Nurse, who agreed that the clinical records did not contain evidence of specific patient care instructions for the aide regarding transfers or alerting the aide to the PEG tube.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review, interview and observation. In 9 of 18 (50%) clinical records reviewed, in which hospice aide services were accepted, revealed that the agency did not ensure the hospice aide provided services ordered by the Interdisciplinary Group and included in the plan of care (POC). Clinical Record 1: The hospice aide care plan, effective 01/11/2023, documented the task to provide activities of daily living (ADLs) services including dressing the patient. On 02/07/2024 a home visit was made with the Aide (Personnel Record 2), who verbally stated the hospice aide applied a Thrombo-Embolic-Deterrent (TED) Hose to both of the patient’s legs every visit. A review of the aide’s completed visit note on 02/07/2024 included documentation that the TED Hose were applied by the aide during the visit. The care plan did not provide the aide with instructions to apply TED Hose. Clinical Record 2: The hospice aide care plan, effective 08/01/2023, documented the task of obtaining the patient’s blood pressure, pulse, temperature, and respirations every visit. The aide visit completed on 01/31/2023 documented that a pulse oximeter reading was obtained. The care plan did not include instructions for the aide to obtain a pulse oximeter reading, and the clinical record did not contain documented evidence to support that the RN had provided verbal instructions to obtain a pulse oximeter reading. Clinical Record 4: The hospice aide care plan, effective 10/07/2023, documented the task of obtaining the patient’s blood pressure, pulse, temperature, and respirations every visit. The aide visits completed on 01/12/2024 and 02/02/2024 documented that pulse oximeter readings were obtained. The care plan did not include instructions for the aide to obtain pulse oximeter readings, and the clinical record did not contain documented evidence to support that the RN had provided verbal instructions to obtain pulse oximeter readings. Clinical Record 5: The hospice aide care plan, effective 11/10/2023, documented the task of obtaining the patient’s blood pressure, pulse, temperature, and respirations every visit. The aide visits completed on 11/12/2023 and 11/21/2023 documented that pulse oximeter readings were obtained. The care plan did not include instructions for the aide to obtain pulse oximeter readings, and the clinical record did not contain documented evidence to support that the RN had provided verbal instructions to obtain pulse oximeter readings. Clinical Record 7: The hospice aide care plan, effective 09/27/2023, documented instructions to provide a shower every visit. The aide documented in the visit narrative notes on 02/05/2024 and 02/07/2024 that the patient was provided a bed bath. The care plan did not provide the aide with instructions to provide a bed bath, and the clinical record did not contain documented evidence to support that the RN had given verbal instructions to provide a bed bath. Clinical Record 12: The hospice aide visit note on 02/07/2024 documented that the patient required two (2) persons to transfer during the visit, a full bed bath was provided, and moisturizer was applied to the skin. The aide also documented that a reddened area was noted at the patient’s sacrum, zinc was applied, and the nurse was aware of the area. The care plan did not include instructions for the aide to provide transfers of the patient, a bed bath, or to apply moisturizer cream to the patient’s skin, and the clinical record did not contain documented evidence to support that the RN had given verbal instructions to perform these tasks. Clinical Record 15: The hospice aide care plan, effective 08/21/2023, documented instructions to obtain the patient’s blood pressure, pulse, temperature, and respirations every visit. The aide visit completed on 08/30/2023 documented that a pulse oximeter reading was obtained. The care plan did not include instructions for the aide to obtain a pulse oximeter reading, and the clinical record did not contain documented evidence to support that the RN had provided verbal instructions to obtain a pulse oximeter reading. Clinical Record 17: The hospice aide care plan, effective 02/20/2023, documented instructions to provide the patient with a shower. The aide’s note dated 02/21/2023 documented that a bed bath was provided; however, the clinical record did not contain documented evidence to support that the RN had provided verbal instructions to change the care plan. Clinical Record 18: The hospice aide care plan effective 06/27/2023 documented instructions to obtain the patient’s blood pressure, pulse, temperature, and respirations every visit. The aide visit completed on 07/11/2023 documented that a pulse oximeter reading was obtained. The care plan did not include instructions for the aide to obtain a pulse oximeter reading, and the clinical record did not contain documented evidence to support that the RN had provided verbal instructions to obtain a pulse oximeter reading. On 02/09/2023 joint clinical record reviews and interviews were conducted with the Chief Operating Officer, Clinical Director, Clinical Coordinator (CC), and Quality Assurance (QA) Nurse, who confirmed that the clinical records contained evidence of the hospice aides performing tasks not included in the plans of care. The QA and CC nurses immediately began educating nursing and aide staff on updating the plans of care (POCs) and following the POCs as written as well as ensuring POCs were updated immediately.”

“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 and interview. In 9 of 18 (50%) clinical records reviewed, in which aide services were accepted, revealed the agency did not ensure the hospice aide reported changes in the patient’s needs to a Registered Nurse (RN). Clinical Record 2: The hospice aide visit completed on 01/31/2024 documented a pulse oximeter reading of 81 percent. Although obtaining a pulse oximeter reading along with parameters to report were not included in the aide care plan, the clinical record did not include documented evidence to support that the aide notified the RN that a reading was obtained and was outside the normal limits. Clinical Record 4: The hospice aide visits completed on 01/12/2024 and 02/02/2024 documented pulse oximeter readings of 88 percent. Although obtaining a pulse oximeter reading along with parameters to report were not included in the aide care plan, the clinical record did not include documented evidence to support that the aide notified the RN that readings were obtained and were outside the normal limits. Clinical Record 5: The hospice aide visit completed on 11/21/2023 documented pulse oximeter readings of 60 percent on the left hand and 85 percent on the right hand. Although obtaining a pulse oximeter reading along with parameters to report were not included in the aide care plan, the clinical record did not include documented evidence to support that the aide notified the RN that readings were obtained and were outside the normal limits. Clinical Record 7: The hospice aide visits completed on 02/05/2024 and 02/07/2024 documented that a bed bath was performed instead of the ordered shower and the patient required two (2) persons to assist when transferring. A review of the clinical record revealed no documented evidence to support the changes in the patient’s condition were reported to the RN to elicit the required changes to the aide’s care plan. Clinical Record 13: The hospice aide visit completed on 02/05/2024 documented a blood pressure reading of 192/93, and on 02/08/2024 the aide documented in the visit narrative a blood pressure reading of 173/73. Although the aide care plan did not include instructions to call regarding specific blood pressure parameters, the clinical record did not include documented evidence to support the aide notifying the RN regarding blood pressure readings outside normal limits. Clinical Record 15: The hospice aide visit completed on 08/30/2023 documented a blood pressure reading of 83/60 as well as documentation that no other assigned tasks were completed because of the family requesting an earlier time for aide visits. The clinical record did not include documented evidence supporting the aide notified the RN of tasks not completed or of the blood pressure reading outside of normal limits. Clinical Record 17: The hospice aide visit completed on 02/21/2023 documented a need to provide the patient with a sponge bath instead of a shower because the patient had increased weakness and stiffness. The clinical record did not provide documented evidence to support that the RN was notified of changes in the patient’s condition that required changes to the care plan. Clinical Record 18: The hospice aide visit completed on 07/11/2023 documented a pulse oximeter reading of 73 percent. Although obtaining a pulse oximeter reading along with parameters to report were not included in the aide care plan, the clinical record did not include documented evidence to support that the aide notified the RN that a reading was obtained and was outside the normal limits. Clinical Record 19: The hospice aide visit completed on 11/01/2023 documented a “blister” on the patient’s left heel, a reddened area on the right foot, and a leaking indwelling catheter. The clinical record did not contain documented evidence that the aide notified the RN of the documented visit findings. On 02/09/2023 joint clinical record reviews and interviews were conducted with the Chief Operating Officer, Clinical Director, Clinical Coordinator, and Quality Assurance Nurse, who reported that the hospice aides called throughout the day to notify the Clinical Director and Clinical Coordinator of changes in patients’ care needs. Leadership confirmed that the clinical records did not include documented evidence from the aides, nurses, or leaders to support notification of changes in patients’ care needs or vital signs.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met as evidenced by clinical record review and interview. In 6 of 18 (33%) clinical records reviewed, in which aide supervision was required, revealed that the agency did not ensure a Registered Nurse (RN) documented a completed aide supervisory visit no less frequently than every 14 days. Clinical Record 6: The plans of care for benefit periods 10/26/2023 - 12/24/2023 and 12/25/2024 - 02/22/2024 included aide frequency of visits two (2) visits per week. The aide completed visits each week as ordered from 12/08/2023 through 01/12/2024. The RN documented an aide supervisory visit on 12/07/2023, and the next supervisory visit was not documented until 01/12/2024 which was 36 days apart. Clinical Record 11: The hospice aide services were ordered starting 12/13/2023 with a visit frequency of one (1) visit per week, and aide visits were completed as ordered. The RN completed the first aide supervisory visit on 01/12/2024 which was 30 days after the first documented hospice aide visit. Clinical Record 15: The initial hospice aide care plan was created by the RN on 08/21/2023 and included the frequency of two (2) visits per week. The aide visit frequency was decreased the week of 09/17/2023 by the RN to one (1) visit per week. The clinical record did not contain documented evidence supporting that the RN completed any supervisory visits from 08/21/2023 through 11/10/2023. Clinical Record 16: The hospice aide care plan was created by the RN on 05/11/2023 and included the frequency of two (2) visits per week starting the week of 05/14/2023. The RN completed the first aide supervisory visit on 07/18/2023 (63 days after the start of aide services). Clinical Record 18: The hospice aide services were ordered starting 06/27/2023. The RN documented an aide supervisory visit was completed on 07/06/2023. The clinical record did not contain documentation to support that the RN completed any additional aide supervisory visits through 08/24/2023 (the patient’s date of death). Clinical Record 19: The hospice aide services were ordered starting 08/01/2023 and included a visit frequency of two (2) visits per week. The RN documented an aide supervisory visit was completed on 08/14/2023, and the next aide supervisory visit was documented on 09/25/2023 which was 42 days apart. On 02/09/2024 joint clinical record reviews and interviews were conducted with the Chief Operating Officer, Clinical Director, Clinical Coordinator, and Quality Assurance Nurse, who confirmed that the clinical records did not contain documented evidence that the aide supervisory visits were completed by the RN every 14 days.”

“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. The record may be maintained electronically or on paper. Each patient’s record includes physician orders for all care and services provided. This standard was not met as evidenced by clinical record review, interview, and observation. In 10 of 19 (53%) clinical records reviewed revealed that the agency did not ensure the clinical record contained physician orders for all care and services provided. Clinical Record 1: The nursing assessment narrative completed on 02/04/2024 documented the patient was wearing a Thrombo-Embolic-Deterrent (TED) Hose to help manage edema. The clinical record did not include evidence of a physician’s order for TED Hose. The clinical record contained uploaded documentation from volunteer visits completed on 12/05/2023, 01/09/2024, and 02/05/2024; however, the clinical record did not contain documented physician orders for volunteer services. Clinical Record 2: On 02/07/2024 a home visit and review of the skilled nursing facility’s treatment orders were conducted with the Registered Nurse (RN) (Personnel Record 1) revealing the following ordered treatments: apply skin prep to bilateral heels two (2) times per day, may test patient for COVID-19 as needed, and may crush medications if not contraindicated. The hospice clinical record did not contain evidence of physician orders for skin prep, COVID-19 testing, and crushing medications. Clinical Record 3: During a home visit with the Medical Social Worker (Personnel Record 3) on 02/07/2024, a copy of the skilled nursing facility’s treatment orders was reviewed revealing the following ordered treatments: confirm wander guard placement on left lower extremity and functioning appropriately, may crush medications and place in apple sauce/pudding, monitor for side effects related to antipsychotic medication, no alcoholic beverages, no blood work, no IVF (intravenous fluid), do not send to the hospital, no weights, and patient to wear B prevalon boots in bed. The hospice clinical record did not contain evidence of physician orders for the wander guard, crushing medications, identified restrictions, and the B prevalon boots. Clinical Record 4: The initial nursing assessment on 10/07/2023 documented an indwelling urinary catheter, and the plan of care (POC) starting 10/07/23 documented orders for the hospice nurse to change every 45 days or as needed as well as an order to irrigate with 60cc of normal saline (NS). The nursing note dated 10/18/2023 documented an order was available to flush the indwelling catheter with 30 - 60cc of NS. The nursing assessment narrative on 11/27/2023 documented that the indwelling catheter was discontinued. The clinical record did not contain evidence of physician orders for the frequency or reason for flushing the indwelling catheter with NS, a range for the NS flush of 30 - 60cc, and discontinuation of the indwelling catheter until 02/08/2024. Clinical Record 6: The nursing assessment completed on 01/03/2023 documented that the patient is diabetic and has a blood sugar checked weekly. The clinical record did not contain evidence of a physician’s order for blood sugar checks. Clinical Record 8: The clinical record contained uploaded documentation from the volunteer for a visit completed on 01/29/2024. The clinical record did not contain documented evidence of a physician order for the volunteer visit. Clinical Record 10: A music therapy physician’s order to evaluate and treat the patient was documented on 06/08/2023. The clinical record contained uploaded documentation from visits completed by the music therapist on 06/13/2023 and 08/09/2023. The clinical record did not contain evidence of a documented physician’s order for the music therapy visit made on 08/09/2023. Clinical Record 15: The clinical record contained uploaded documentation of music therapy visits completed on 10/05/2023, 10/26/2023, and 11/02/2023. The clinical record did not contain documented physician orders for music therapy. Clinical Record 16: A massage therapy physician’s order to evaluate and treat the patient was documented on 05/29/2023, and the clinical record contained uploaded documentation from a visit completed by the massage therapist on 07/13/2023. The clinical record contained uploaded documentation of a second visit made by the massage therapist on 07/28/2023; however, the clinical record did not contain documented evidence of a physician’s order for the second visit. On 02/09/2023 joint clinical record reviews and interviews were conducted with the Chief Operating Officer, Clinical Director, Clinical Coordinator, and Quality Assurance Nurse, who confirmed the clinical records did not include evidence of physician orders for all care and services provided including TED Hose, discontinuation of indwelling catheter and specific flush orders, facility treatment orders, music therapy, volunteer services, and massage therapy.”

“This standard was not met as evidenced by clinical record review, interview, and observation. In 2 of 2 (100%) home visits completed, in which the patient resided in a Skilled Nursing Facility (SNF), revealed the agency did not ensure the hospice medication information was provided to the SNF. Home Visit 2: During a home visit with the Registered Nurse (RN) (Personnel Record 1) on 02/07/2024, the RN was observed completing a reconciliation of the patient’s medications using the skilled nursing facility (SNF) medication list and the hospice medication list. The hospice medication profile included medications not found on the SNF medication profile including Cyanocobalamin (Vit B-12) ER 1,000 mcg, Haloperidol lactate 2mg/mL, Ipratropium 0.5mg-Albuterol 3mg nebulization solution, Lorazepam Intensol 2mg/mL, Mirtazapine 7.5mg, Nystatin 100,000u/gram powder, and Sertraline 50mg. The clinical record did not contain documented evidence supporting hospice medication information was provided to the SNF. Home Visit 3: During a home visit with the Medical Social Worker (Personnel Record 3) on 02/07/2024, a copy of the current medication and treatment orders used by the SNF was requested and provided by the SNF nurse. The hospice medication profile included medications not found on the SNF medication profile including Compazine 25mg rectal suppository, scheduled Morphine Concentrated 100mg/5mL, Nystatin 100,000u/gram, O2-Oxygen Humidified, Salonpas (Lidocaine) 4% topical patch, and Sertraline 25mg. The clinical record did not contain documented evidence supporting hospice medication information was provided to the SNF. On 02/09/2023 joint record reviews and interviews were conducted with the Chief Operating Officer, Clinical Director, Clinical Coordinator, and Quality Assurance Nurse, who confirmed the clinical records did not contain documented evidence supporting hospice medication information was provided to the SNF.”