DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
101555 A. BUILDING __________
B. WING ______________ 		03/23/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
ACCENTCARE HOSPICE & PALLIATIVE CARE OF BROWARD CO 1200 S PINE ISLAND RD STE 300, PLANTATION, FL, 33324
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0540      
33162 Based on review of the Hospice's Policy and Procedure, record review and interview, the Hospice failed to ensure a Registered Nurse (RN) assessed patient needs and coordinated care throughout the level of care and location changes for 1 of 5 sampled patients (Patient #1). The findings included: Review of the Hospice's Policy and Procedure titled, "Change in Level of Care / Change in Location," revised 10/24/17 documents under Purpose, "To ensure that the electronic record reflects the current LOC (Level of Care) and any needs, changes, care plan, and orders related to this event" and under Protocol, in relevant parts, "The registered nurse case manager (RNCM) or designee obtains orders for the new LOC or change in location, including medications and visit frequencies" and "Once the change in LOC order is obtained and insurance is confirmed, the RNCM will complete the following: a. Document the LOC change... b. Adjust the visit frequency orders to meet the needs of the patient for this new LOC c. Update the goals, problems, and interventions in the Care Plan to reflect the needs of the patient and family, including the Hospice Aide care plan as appropriate d. Complete the Nurse Reassessment Profile and the Fall Risk Assessment Profile..." Review of the Hospice's Policy and Procedure titled, "Change in Level of Care / Change in Location," revised 10/24/17 reveals no evidence of timeliness of assessment after level of care or location changes to identify and coordinate or address patient care needs in their new setting or environment. Review of the record reveals Patient #1 was admitted to the Hospice Inpatient Unit for "General Inpatient Care" on 10/22/21. Patient #1's "Hospice Certification and Plan of Care" for the certification period beginning 10/22/21 includes for the Hospice nurse to perform wound care to the sacrum (above the tailbone) every day and PRN ("as needed"). Patient #1's records document the patient was transferred and admitted to a Skilled Nursing facility with Hospice care on 11/04/21. A "Hospice Physician Order" dated 11/05/21 at 10:46 AM, entered and electronically signed by Team Director "A" on 11/05/21, documents to transfer Patient #1 from the Hospice "Inpatient Unit" to the Skilled Nursing facility and the level of care as, "Routine Home Care" effective 11/05/21 including Skilled Nurse visits effective 10/31/21 for 10 visits the first week, then "1 (visit) every 9 (times a week) wk (for) 9 (weeks)" and 3 visits PRN ("as needed") for crisis management; Home Health Aide visits effective 10/31/21 for 12 visits for one week. Further review of the record reveals no evidence of documentation that Patient #1 was seen by Hospice staff in the Skilled Nursing facility from 11/04/21 to 11/10/21, or of a Hospice Plan of Care that addresses coordination of care with the Skilled Nursing facility staff to meet Patient #1's care needs. During an interview on 03/21/22 at 3:31 PM, Team Director A stated she was not informed by staff when Patient #1 transferred from the Inpatient Unit to the Skilled Nursing facility, which she confirmed is served by her "team" and only learned Patient #1 was at the Skilled Nursing facility when a staff member e-mailed her on 11/08/21 notifying that the family wanted Patient #1 to be transferred from the Skilled Nursing facility to their home as soon as possible. During interview on 03/21/22 at 3:04 PM, Team Director A explained the frequencies on the physician's order dated 11/05/21 did not apply to her time in the Skilled Nursing facility but were retroactive to Patient #1's stay on the Hospice Inpatient Unit since they were not previously ordered; Team Director A stated a nurse is supposed to do a nurse assessment the day of or day after a patient transfer but did not acknowledge that it was herself who transcribed Patient #1's transfer order on 11/05/21, the day after the transfer and failed to assign and notify an RN Case Manager. During further interview on 03/23/22 at 11:01 AM, Team Director A verified Patient #1 did not receive a visit from Hospice staff in the Skilled Nursing facility, from 11/04/21 to 11/10/21 but Team Director A continued to report that she was not informed that Patient #1 was transferred to the Skilled Nursing facility until an e-mail she received on 11/08/21; when shown, during this interview, that she herself had electronically signed the transfer order dated 11/05/21, Team Director A admitted it was her responsibility to notify the RNCM (Registered Nurse Case Manager) to see the patient in the Skilled Nursing facility after transfer. Upon inquiry to the meaning of the nurse visit frequency "1every 9wk 9," Team Director A was unable to explain what that means but said the software program created that entry after she charted nurse visits on Thursdays and that the RNCM could assess the patient and update visit frequencies; Team Director A did not acknowledge that after Patient #1 was transferred to the Skilled Nursing facility on 11/04/21, Thursday, for which she herself wrote the transfer order on 11/05/21, that it was her responsibility to assign an RNCM and schedule their visit the day of or following transfer, which she did not do but scheduled an LPN (Licensed Practical Nurse) visit for the following Thursday, 11/11/21. The Skilled Nursing facility's "Discharge Plan and Instructions" documents Patient #1 went home with Hospice services on 11/10/21. Review of the Hospice physician's orders reveal no evidence of documentation of a change to the wound care physician's orders since they had been ordered daily on 10/22/21 and no revision to the Plan of Care to ensure daily wound care in the home, as ordered. A "Clinical Coordination Note," dated 11/10/21 documents the patient was going home from the Skilled Nursing facility with medications that day, transportation arranged, family requested a nurse visit the next day and "will send nurse to evaluate for DME (Durable Medical Equipment), medications and health status." An LPN's "Visit Note Report" dated 11/11/21 documents wound care to the sacrum was completed and "Hospice RN" to evaluate patient and develop a Nursing Plan of Care." A physician's order dated 11/11/21, entered and electronically signed by Team Director A, documents Skilled Nursing visits weekly for 9 weeks beginning 11/14/21 and does not address the need for daily wound care. An RN's "Visit Note Report" dated 11/13/21 documents an "as needed" visit per family request for wound care, that wound care to the sacrum was completed, that the family reported no visit or supplies were received since Patient #1's transfer home, that the RN promised to follow up with the Team Manager and get back to them and "Hospice RN to evaluate patient and develop a Nursing Plan of Care." Further review of the Nurse's Note and "Coordination Notes" provided no evidence of follow up or further contact to the patient/family from that Nurse. An RN's "Visit Note Report" dated 11/16/21 documents the Nurse performed wound care and "Hospice RN to evaluate patient and develop a Nursing Plan of Care." During interview on 3/21/22 at 3:04 PM, Team Director A reported Patient #1 came to her team on 11/12/21 and she had a Nurse visit the patient at home on 11/13/21; Team Director A reported an LPN also visited Patient #1 in the Skilled Nursing facility on 11/11/21; however, concurrent review of the LPN's "Visit Note" from 11/11/21 revealed that visit took place in Patient #1's personal residence not the Skilled Nursing facility and the RN's visit note from 11/13/21 documented that was an "as needed" not scheduled visit in response to the family's calls requesting wound care and pain medicine, during which the family reported Patient #1 had received no visits or supplies since the patient was transferred home on 11/10/21. During interview on 03/23/22 at 1:14 PM, the Director of Clinical Services stated their process when a patient goes home is for the RNCM to visit and do a head-to-toe assessment, get any necessary medication orders, teach the family about medications including side effects and ensure the family can give the medications, assess their needs including to identify supplies needed, and to revise the Plan of Care. During further interview on 03/23/22 at 11:01 AM with inquiry to whether she reviewed Patient #1's Plan of Care to see that wound care was needed daily, Team Director A stated she entered a 'Weekly Nurse Visit" and the Nurse could update the frequency order; reported she arranged Patient #1's transport home on 11/10/21 but was "short-staffed" and did not have an RN to send, so she had an LPN visit the patient on 11/11/21 rather than tell the "Leadership Team" she needed an RN to make a visit; during this interview, the Clinical Support Specialist, also present stated at that time they had a full-time Registered Nurse who could have made the visit after hours if this had been communicated; Team Director A did not verbalize a process to ensure timely visits with level of care or location changes or that anything should have been done differently with her handling of this patient.
L0543      
33162 Based on review of the Hospice's Policy and Procedure, record review and interview, the Hospice failed to ensure Nursing Services established and followed an individualized Plan of Care for 3 of 5 patients (Patient #1, #3 and #4). The findings included: 1) Review of the Hospice Policy and Procedure titled, "Plan Of Care", revised 02/21/20 documents under Policy, "The interdisciplinary group (IDG) will collaborate to develop and maintain a plan of care, treatment and services that is individualized and appropriate to the needs, strengths, limitations and goals for each patient/family admitted to the hospice program as it relates to the terminal illness and related conditions. The care provided to the patient will be in accordance with the physicians' orders and the plan of care (POC). The POC will emphasize prevention and control of pain and other distressing symptoms and optimize comfort and dignity" and under Procedures, "1. All hospice care and services furnished to patients and their families will follow an individualized written POC in accordance with the patient's and family's medical, social, nutritional, and psychological needs and goals (the patient's needs and goals are a priority). The POC is established by the IDG in collaboration with the attending physician (if any) and with the patient or representative and the primary caregiver, if any of them so desire.... a) Upon completion of the nursing assessment, the comprehensive POC will be initiated to address the needs identified in the assessment... b) Based on the information gathered in the comprehensive assessment, the POC will be updated to reflect patient and family goals and will include all interventions needed to address the problems identified in the comprehensive assessment..." and "2. The comprehensive POC will include the patient's diagnosis and all services necessary for the palliation and management of the terminal illness and related conditions, including the following: a) Interventions to manage pain, symptoms, and grief, including the level of care to be provided and any safety measures employed to protect the patient from harm; b) A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs; c) Measurable outcomes anticipated from implementing and coordinating the POC; d) Drugs and treatments necessary to meet the needs of the patient; e) Medical supplies, assistive devices and appliances necessary to meet the needs of the patient; f) The IDG's documentation of the patient's or representative's level of understanding, involvement, and agreement with the POC; g) Designation of the primary caregiver or alternate plan to provide 24-hour care and support in the patient's home to ensure that the patient's needs will be met; h) Plans for instructing and educating the patient/family and the designated caregiver as appropriate to their responsibilities for the care and services identified in the POC; i) Identification of advance directives; j) Plans and arrangements for after the patient's death, once known; and k) Physicians' orders...FL (in Florida): A description of how needed care and services will be provided in the event of an emergency. 3.The hospice IDG in collaboration with the individual's attending physician, if any, will review, revise, and document the individualized POC as frequently as the patient's condition requires but no less frequently than every (15) days; the review must be documented in writing. Communication with the attending physician may be through phone calls, orders received and mailing an updated interdisciplinary POC every (15) days..." and "4. A POC must include information from the patient's updated comprehensive assessment and must note the patient's progress toward outcomes and goals specified in the POC. 5. Seasons Hospice will designate a registered nurse that is a member of the IDG to provide coordination of care and to ensure continuous assessments of each patient's and family's needs and implementation of the interdisciplinary POC. The designated registered nurse is responsible for ensuring that the updated plans of care are placed in the patient's facility or home chart. 6. The IDG will maintain and document a system of communication to: a) Ensure that the IDG maintains responsibility for directing, coordinating and supervising the care and services provided; b) Ensure that the care and services are provided in accordance with the POC; c) Ensure that the care and services provided are based on all assessments of the patient's and family's needs; d) Provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangements; e) Provide for an ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. All communications will be documented in the patient's medical record; and f) Ensure the referral of the patient to appropriate agencies for needed services not provided by Seasons Hospice. 7. The written POC will be maintained in the patient's medical record and will be available to all personnel providing patient care. The patient and/or family will have access to the written POC upon request." Review of the record reveals Patient #1 was admitted to the Hospice Inpatient Unit for "General Inpatient Care" on 10/22/21. Patient #1's "Hospice Certification and Plan of Care" for the certification period beginning 10/22/21 includes for the Hospice nurse to perform wound care to the sacrum (above the tailbone) every day and PRN ("as needed"). Patient #1's records document the patient was transferred and admitted to a Skilled Nursing facility with Hospice care on 11/04/21. A "Hospice Physician Order" dated 11/05/21 at 10:46 AM, entered and electronically signed by Team Director "A" on 11/05/21, documents to transfer Patient #1 from the Hospice "Inpatient Unit" to the Skilled Nursing facility and the level of care as, "Routine Home Care" effective 11/05/21 including Skilled Nurse visits effective 10/31/21 for 10 visits the first week, then "1 (visit) every 9 (times a week) wk (for) 9 (weeks)" and 3 visits PRN ("as needed") for crisis management; Home Health Aide visits effective 10/31/21 for 12 visits for one week. Further review of the record reveals no evidence of documentation that Patient #1 was seen by Hospice staff in the Skilled Nursing facility from 11/04/21 to 11/10/21, or of a Hospice Plan of Care that addresses coordination of care with the Skilled Nursing facility staff to meet Patient #1's care needs. During an interview on 03/21/22 at 3:31 PM, Team Director A stated she was not informed by staff when Patient #1 transferred from the Inpatient Unit to the Skilled Nursing facility, which she confirmed is served by her "team" and only learned Patient #1 was at the Skilled Nursing facility when a staff member e-mailed her on 11/08/21 notifying that the family wanted Patient #1 to be transferred from the Skilled Nursing facility to their home as soon as possible. During interview on 03/21/22 at 3:04 PM, Team Director A explained the frequencies on the physician's order dated 11/05/21 did not apply to her time in the Skilled Nursing facility but were retroactive to Patient #1's stay on the Hospice Inpatient Unit since they were not previously ordered; Team Director A stated a nurse is supposed to do a nurse assessment the day of or day after a patient transfer but did not acknowledge that it was herself who transcribed Patient #1's transfer order on 11/05/21, the day after the transfer and failed to assign and notify an RN (Registered Nurse) Case Manager. During further interview on 03/23/22 at 11:01 AM, Team Director A verified Patient #1 did not receive a visit from Hospice staff in the Skilled Nursing facility, from 11/04/21 to 11/10/21 but Team Director A continued to report that she was not informed that Patient #1 was transferred to the Skilled Nursing facility until an e-mail she received on 11/08/21; when shown, during this interview, that she herself had electronically signed the transfer order dated 11/05/21, Team Director A admitted it was her responsibility to notify the RNCM (Registered Nurse Case Manager) to see the patient in the Skilled Nursing facility after transfer. Upon inquiry to the meaning of the nurse visit frequency "1every 9wk 9," Team Director A was unable to explain what that means but said the software program created that entry after she charted nurse visits on Thursdays and that the RNCM could assess the patient and update visit frequencies; Team Director A did not acknowledge that after Patient #1 was transferred to the Skilled Nursing facility on 11/04/21, Thursday, for which she herself wrote the transfer order on 11/05/21, that it was her responsibility to assign an RNCM and schedule their visit the day of or following transfer, which she did not do but scheduled an LPN (Licensed Practical Nurse) visit for the following Thursday, 11/11/21. The Skilled Nursing facility's "Discharge Plan and Instructions" documents Patient #1 went home with Hospice services on 11/10/21. Review of the Hospice physician's orders reveal no evidence of documentation of a change to the wound care physician's orders since they had been ordered daily on 10/22/21 and no revision to the Plan of Care to ensure daily wound care in the home, as ordered. A "Clinical Coordination Note," dated 11/10/21 documents the patient was going home from the Skilled Nursing facility with medications that day, transportation arranged, family requested a nurse visit the next day and "will send nurse to evaluate for DME (Durable Medical Equipment), medications and health status." An LPN's "Visit Note Report" dated 11/11/21 documents wound care to the sacrum was completed and "Hospice RN" to evaluate patient and develop a Nursing Plan of Care." A physician's order dated 11/11/21, entered and electronically signed by Team Director A, documents Skilled Nursing visits weekly for 9 weeks beginning 11/14/21 and does not address the need for daily wound care. An RN's "Visit Note Report" dated 11/13/21 documents an "as needed" visit per family request for wound care, that wound care to the sacrum was completed, that the family reported no visit or supplies were received since Patient #1's transfer home, that the RN promised to follow up with the Team Manager and get back to them and "Hospice RN to evaluate patient and develop a Nursing Plan of Care." Further review of the Nurse's Note and "Coordination Notes" provided no evidence of follow up or further contact to the patient/family from that Nurse. An RN's "Visit Note Report" dated 11/16/21 documents the Nurse performed wound care and "Hospice RN to evaluate patient and develop a Nursing Plan of Care." During interview on 3/21/22 at 3:04 PM, Team Director A reported Patient #1 came to her team on 11/12/21 and she had a Nurse visit the patient at home on 11/13/21; Team Director A reported an LPN also visited Patient #1 in the Skilled Nursing facility on 11/11/21; however, concurrent review of the LPN's "Visit Note" from 11/11/21 revealed that visit took place in Patient #1's personal residence not the Skilled Nursing facility and the RN's visit note from 11/13/21 documented that was an "as needed" not scheduled visit in response to the family's calls requesting wound care and pain medicine, during which the family reported Patient #1 had received no visits or supplies since the patient was transferred home on 11/10/21. During interview on 03/23/22 at 1:14 PM, the Director of Clinical Services stated their process when a patient goes home is for the RNCM to visit and do a head-to-toe assessment, get any necessary medication orders, teach the family about medications including side effects and ensure the family can give the medications, assess their needs including to identify supplies needed, and to revise the Plan of Care. During further interview on 03/23/22 at 11:01 AM with inquiry to whether she reviewed Patient #1's Plan of Care to see that wound care was needed daily, Team Director A stated she entered a 'Weekly Nurse Visit" and the Nurse could update the frequency order; reported she arranged Patient #1's transport home on 11/10/21 but was "short-staffed" and did not have an RN to send, so she had an LPN visit the patient on 11/11/21 rather than tell the "Leadership Team" she needed an RN to make a visit; during this interview, the Clinical Support Specialist, also present stated at that time they had a full-time Registered Nurse who could have made the visit after hours if this had been communicated; Team Director A did not verbalize a process to ensure timely visits with level of care or location changes or that anything should have been done differently with her handling of this patient. 2) Review of the record reveals Patient #3 was admitted to the Hospice on 01/22/22, revoked Hospice to pursue aggressive care on 03/08/22 and was re-admitted to the Hospice on 03/12/22. Patient #3's "Visit Note Report" for "RN Start Of Care" dated 03/12/22 documents the patient had unstageable pressure wounds with chronic Osteomyelitis (bone infection) to the sacrum and both heels and required wound care daily and "PRN." Patient #3's wound care orders documented on Patient #3's "Visit Note Report" for "RN Start Of Care" dated 03/12/22 included to daily and PRN ("as needed") cleanse the sacral wound with Normal Saline, pat dry, apply Aquacel Ag (wound treatment) 4x4 inch sheet and cover with large "Aquacel foam Pro sacral dressing" and for the bilateral heels to paint with Betadine, use foam dressing, wrap daily and "PRN". Patient #3's electronic Hospice Orders dated 03/12/22 (Saturday) with "Order Type" as "Hospice Plan of Care" document sacral wound care "utilizing clean technique - cleanse with normal saline. Apply Aquacel Ag 4x4 to wound bed, cover with foam adhesive dressing and change every 3 days and PRN. Instruct caregiver in wound care" and "Bilateral heels paint with betadine, offload heels... daily, can wrap in foam with Kerlix." Patient #3's handwritten "Interim Plan of Care" dated 03/12/22 documents, "patient will require wound care 3 x (times) a week (T-Th-S) (Tuesdays, Thursdays and Saturdays), but contains no directions, goals, or sites for wound care and documents the Plan of Care was discussed with RN B. Patient #3's handwritten "Nurse Visit Note" dated 03/18/22 (Friday) by RN B documents "Wounds" as "Sacral wound Stage 4" and "Integumentary (skin)/Wounds Treatment Supporting Documentation" as "Tx (treatment) Medihoney, Zinc cream, wound cleanser, Dermaginate - wound care 3 day a week and PRN. Treated with Medihoney. Provided wound care as ordered, no redness or any s/s (signs/symptoms) of infection noted to wound site." This "Nurse Visit Note" dated 03/18/22 documents the "Plan for Next Visit/Shift" as "continue with visits 3 days a week & PRN for wound care." There is no evidence RN B documented wound care to Patient #3's heels as the physician ordered. During interview on 03/21/22 at 2:29 PM, the Director of Clinical Services explained that there was a computer "glitch", so they had to use paper records for Patient #3 but that all the care was provided and documented on paper. During interview on 03/23/22 at 2:30 PM, Team Director A reported wound care for Patient #3 was ordered 3 times weekly, but she was unable to see the electronic orders due to the computer "glitch" until 03/18/22 and the Admitting Nurse did not tell her of this physician's order, so she could not schedule the Nurse accordingly. During interview with the Executive Director and Team Director A on 03/23/22 at 2:39 PM, the Executive Director reviewed an e-mail from Patient #3's Admitting Nurse to the "Team," including to Team Director A, notifying the "Team" of the admission and that Patient #3 required wound care daily and "PRN." During this interview, Team Director A reported RN B also visited Patient #3 on 03/22/22 but that visit note was not available and RN B "called off "this day (03/23/22). Team Director A and the Director of Clinical Services could not provide evidence of physician's orders for Patient #3's daily wound care as documented in the Start of Care visit, to change the wound care frequency from every 3 days to Tuesdays, Thursdays, and Saturdays as documented on the Interim Plan of Care dated 03/12/22, to change the wound care regimen to use Medihoney, Zinc cream, and Dermaginate as documented in the Nurse Visit on 03/18/22 or that patient could skip wound care on 03/15/22 and 03/21/22 instead of having wound care every 3 days as previously ordered on 03/12/22. Several telephone calls were placed to RN B, but she could not be reached on 03/22/22 or 03/23/22. 3) Review of the record revealed Patient #4 was admitted to the Hospice on 03/01/22. Patient #4's "Hospice Certification and Plan of Care" for the certification period beginning 03/01/22 documented for 3 Skilled Nurse visits the first week of care, then once weekly for 12 weeks. Further review of the record revealed Patient #4 received Skilled Nurse visits on 03/01/22 and 03/02/22 but did not receive a 3rd visit that week as the physician ordered. The Clinical Support Specialist reviewed the record and verified she could find no evidence of changed orders for Patient #4's Skilled Nurse visit frequencies in the first week of care, during an interview on 03/23/22 at 5:00 PM.
L0773      
33162 Based on review of the Hospice's Policy and Procedure, record review and interview, the Hospice failed to coordinate with the Skilled Nursing facility for a Plan of Care and to provide Hospice services in the Skilled Nursing facility for 1 of 5 patients (Patient #1). The findings included: Review of the Hospice's Policy and Procedure titled, "Change in Level of Care / Change in Location," revised 10/24/17 documents under Purpose, "To ensure that the electronic record reflects the current LOC (Level of Care) and any needs, changes, care plan, and orders related to this event" and under Protocol, in relevant parts, "The registered nurse case manager (RNCM) or designee obtains orders for the new LOC or change in location, including medications and visit frequencies" and "Once the change in LOC order is obtained and insurance is confirmed, the RNCM will complete the following: a. Document the LOC change... b. Adjust the visit frequency orders to meet the needs of the patient for this new LOC c. Update the goals, problems, and interventions in the Care Plan to reflect the needs of the patient and family, including the Hospice Aide care plan as appropriate d. Complete the Nurse Reassessment Profile and the Fall Risk Assessment Profile..." Review of the Hospice's Policy and Procedure titled, "Change in Level of Care / Change in Location," revised 10/24/17 reveals no evidence of timeliness of assessment after level of care or location changes to identify and coordinate or address patient care needs in their new setting or environment nor does it address coordination of care with transfers to residential facilities. Review of the record reveals Patient #1 was admitted to the Hospice Inpatient Unit for "General Inpatient Care" on 10/22/21 and was transferred to a Skilled Nursing facility for "Routine Home Care" on 11/04/21. The Skilled Nursing facility's "Discharge Plan and Instructions" documents Patient #1 went home on 11/10/21. Further review of the record reveals no evidence of documentation that Patient #1 was seen by Hospice staff during their time in the Skilled Nursing facility, from 11/05/21 to 11/10/21, or of a Hospice Plan of Care to address their needs while in the Skilled Nursing facility. During interview on 3/21/22 at 3:04 PM, Team Director A reported Patient #1 came to her "Team" on 11/12/21 and she had a Nurse visit the patient on 11/13/21; Team Director A reported an LPN (Licensed Practical Nurse) visited Patient #1 in the Skilled Nursing facility on 11/11/21, however concurrent review of the LPN's "Visit Note" from 11/11/21 revealed that this "visit" took place in the patient's personal residence, not the Skilled Nursing facility. During further interview on 03/31/22 at 3:31 PM, Team Director A stated they were not informed by staff when Patient #1 was transferred from the Hospice "Inpatient Unit" to the Skilled Nursing facility and only learned Patient #1 was at the Skilled Nursing facility when a staff member e-mailed her on 11/08/21 notifying that the family wanted Patient #1 to be transferred from the Skilled Nursing facility to their home as soon as possible. A "Hospice Physician Order" dated 11/05/21 at 10:46 AM, entered and electronically signed by Team Director A on 11/05/21, documents to transfer Patient #1 from the Hospice "Inpatient Unit" to the Skilled Nursing facility and the level of care as "Routine Home Care" effective 11/05/21; Skilled Nurse visits effective 10/31/21 for 10 visits the first week, then 1 (visit) every 9 (times a week) wk (for) 9 (weeks)" and 3 visits PRN ("as needed") for crisis management and Home Health Aide visits effective 10/31/21 for 12 visits the first week. During interview on 03/21/22 at 3:04 PM, Team Director A reported the frequencies on the physician's order dated 11/05/21 were retroactive to Patient #1's stay on the Hospice "Inpatient Unit" since they were not previously ordered and had nothing to do with the Skilled Nursing facility stay; stated a nurse is supposed to do a Nurse Assessment the day of or day after patient transfer; did not acknowledge that she herself had transcribed that transfer order and therefore knew of Patient #1's transfer to her own "Team" and the Skilled Nursing facility by at least 11/05/21 and failed to establish visit frequencies for Patient #1 to be seen by Hospice staff in the Skilled Nursing facility. During further interview on 03/23/22 at 11:01 AM, Team Director A verified Patient #1 did not receive a visit from Hospice staff in the Skilled Nursing facility, from 11/04/21 to 11/10/21 but Team Director A continued to report that she was not informed that Patient #1 was transferred to the Skilled Nursing facility until an e-mail she received on 11/08/21; when shown, during this interview, that she herself had electronically signed the transfer order dated 11/05/21, Team Director A admitted it was her responsibility to notify the RNCM (Registered Nurse Case Manager) to see the patient in the Skilled Nursing facility after transfer. Upon inquiry to the meaning of the nurse visit frequency "1every 9wk 9," Team Director A was unable to provide clarification but said the software program created that entry after she charted Nurse Visits on Thursdays and that the Visiting Nurse could assess and update visit frequencies; Team Director A did not acknowledge that although Patient #1 was transferred to the Skilled Nursing home on 11/04/21, Thursday, for which she herself wrote the transfer order on 11/05/21, Team Director A did not schedule a Skilled Nursing visit to Patient #1 until the following Thursday, 11/11/21; Team Director A did not verbalize a process to ensure timely visits with level of care changes or coordination of Hospice care with Skilled Nursing facilities for patients on her team.