Survey Report for 151615

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
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	151615	A. BUILDING __________ B. WING ______________	08/07/2020
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
PHYSIOCARE HOSPICE LLC	1440 INNOVATION PLACE, WEST LAFAYETTE, IN, 47906
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)
L0505
L0505	42617 Based on record review and interview, the hospice agency failed to ensure agency employees adhered to the agency's complaint policy, which required all complaints be documented and complainants receive notification of the investigation and resolution of complaints, for 3 of 6 complaints reviewed (Patient #3, 4, 6). Findings include: 1. An agency policy, revised December 2018, titled "Complaint/Grievance Policy No. 0-003," stated " ... Any difference of opinion, dispute, or controversy between a patient or family/caregiver or patient representative and Physiocare Hospice concerning any aspect of services or the application of policies and procedures will be considered a grievance ... the organization staff member receiving the complaint will discuss ... the grievance with a supervisor within five (5) days after receipt of such grievance and will make every effort to resolve the grievance to the patient's satisfaction. Response to the patient regarding the complaint will occur within ten (10) days of receipt ... If a grievance cannot be resolved to the patient's satisfaction, the patient or his/her representative is to notify, verbally or in writing, the Executive Director/Administrator ... The Executive Director/Administrator or designee will then investigate the grievance and contact the patient or his/her representative regarding the grievance in an attempt to resolve the differences. The Executive Director/Administrator will respond to the patient within ten (10) days of notification of failure to resolve the complaint ... If a patient feels his/her grievance has not been resolved after working with Physiocare Hospice personnel, he/she will be informed of his/her right to notify the state or [accrediting body] via the respective toll-free telephone numbers ... Complaints and any action taken will be documented on a complaint form ... Resolution information will be communicated in writing to the patient and his/her representatives filing the complaint ..." 2. The Entrance Conference was conducted on 8/5/2020 at 11:45 AM with the administrator. The administrator indicated she and the agency's Director of Compliance were assigned the task of documenting, investigating, and resolving complaints. The administrator stated when a complaint came in to the agency, the Director of Compliance took down the details of the initial complaint from the complainant and gathered "all the info." The administrator and Director of Compliance then discussed the investigation and determined findings, and the Director of Compliance notified the complainant of the investigation findings and resolution. The administrator also indicated complaints could be documented electronically or on paper. 3. The agency's Complaint Log from 10/21/18 to 8/5/2020 was reviewed on 8/5/2020. A complaint was documented within the log on 5/23/19 at 9:00 PM by the agency's Director of Compliance. The employees noted to be the "Person Receiving Call" were Employee C, Registered Nurse, and the Director of Compliance. Person E, family member of Patient #3, was noted to be the person making the complaint. The "Nature of Complaint/ Customer Concern" was documented as "[Person E] called on-call # to complain [sic]: pt [patient] death ... was caused by moving her bedroom downstairs from upstairs ... That hospice staff contacted protective services [with] concerns regarding pt. care, home environment and care of pt's children ... That The [sic] hospice LPN [Former Employee F] made disparaging remarks about pt. family on [social media]." Immediate action noted on the complaint form was documented to be "[Director of Compliance] immediately called [Person E] back. She repeated same claims and wanted 'someone with the state' to call. Gave [complainant] The state complaint hotline [sic]. "Administrative active taken" was documented as "[Follow up] with LPN [Former Employee F]. She detailed how the pt's aggressive cancer was cause of death. [Former Employee F] also denies all claims regarding family comments of [social media] [sic]. No comments found online. [Director of Compliance] updated [Administrator]. The resolution of the compliant stated "[Person E's] claims unfounded. Determined she is angry at losing financial assistance through patient's children (kids were removed from her home The same day as The call on 5/23 [sic]). LPN also spoke with other family - all disregard [Person E]." The complaint report failed to indicate a date of resolution or date and time the complainant was notified of the investigation and findings of her complaint. An undated, untitled, and unsigned document was attached to the agency's complaint report, which the Director of Compliance identified as his notes taken during the complaint investigation. This document stated "[Former Employee F] shared threatening text message sent to her from [complainant]." Also attached to the complaint report was a screenshot from an iPhone of an undated text message received at 9:09 PM stating, "You're a lowdown dirty B***H karma is a tucker [sic] then you die." The Director of Compliance indicated the screenshot was taken from Former Employee F's phone, and the message was sent from the complainant to Former Employee F. An interview was conducted with Person E, family member of Patient #3 (hospice election date 3/19/19, discharge date 5/8/19 due to patient death), on 8/7/20 at 9:20 AM. Person E reported she did file a complaint with the hospice agency regarding her concerns with the care Patient #3 received from Former Employee F. Person E reported she spoke with a "male supervisor" at the agency, but could not recall the employee's name or title. Person E stated she "never heard anything back" regarding investigation or resolution of her complaint to the agency. 4. An interview with Person K, family member of Patient #4 (hospice election date 6/22/19, discharge date 7/8/19 due to transfer to another hospice agency), was conducted on 8/6/20 at 1:41 PM. Person K indicated she did contact the hospice agency to report she was not pleased with the care Patient #4 was receiving. Person K did not recall the name of the employee she spoke with at the agency, and would not provide further details on what specific concerns she reported. Person K stated she was told the agency would "look into [her concerns] and get back with" her. Person K indicated she never heard back from the agency regarding her complaint. 5. An interview with Person J, family member of Patient #6 (hospice election date 5/12/2020, discharge date 7/24/2020 due to transfer to another hospice agency), was conducted on 8/7/2020 at 11:04 AM. During the interview, Person J indicated she did report a complaint to the agency regarding Employee C's conduct. Person J stated Employee C "didn't treat [Patient #6] with respect ... I think it was a personality issue ... issue with manners." Person J declined to provide further detail on Employee C's actions or behavior during the visit. Person J indicated she reported her concern to agency staff, but did not recall who she reported it too, and Employee C did not return to the patient's home. The agency's Complaint Log and Employee C's personnel file failed to include this complaint. 6. An interview with the administrator and Director of Compliance was conducted on 8/7/2020 at 3:45 PM. The administrator indicated all patient and families who reported a complaint should be informed of the investigation findings. The Director of Compliance indicated Person E was not informed of the findings of her complaint made to the agency regarding Former Employee F. The Director of Compliance stated he "probably" could have notified Person E of the complaint investigation and resolution through phone call or mail, but "it wouldn't help." The Director of Compliance also indicated Person E had sent threatening messages to Former Employee F, and the administrator indicated Person E had "cut off all communication" with the agency. 7. A follow up interview with the administrator and Director of Compliance was conducted on 8/7/2020 at 4:55 PM. The Director of Compliance indicated Person E was very angry and "cussing" when she reported her complaint to him, and Person E threatened both the Director of Compliance and Former Employee F. The Director of Compliance failed to provide specific statements made by Person E to himself, but did report a copy of a threatening text message sent to Former Employee F from Person E was included within the complaint investigation paperwork. The Director of Compliance stated he gave Person E the phone number to report her complaint to the state department of health's complaint hotline, and he "thought that resolved [the complaint] ... nothing was going to make [Person E] happy ... she was upset because we took her source of income away ... the patient had passed several weeks before [Person E made the complaint]."
L0536
L0536	42617 Based on record review and interview, the hospice agency failed to ensure the plan of care contained updated, accurate, and individualized treatments and intervention (See Tag L538), and failed to ensure the plan of care contained specific, individualized, and measurable outcomes for patient and/or caregiver goals (See Tag L548). These practices impacted day-to-day operations of the agency and care provided to all patients of the agency. The cumulative effect of this systemic problem resulted in the agency being out of compliance with the Condition of Participation 42 CFR 418.56 Interdisciplinary group, Care planning, and coordination of services.
L0538
L0538	42617 Based on record review and interview, the hospice agency failed to ensure the plan of care contained updated, accurate, and individualized treatments and interventions for 4 of 5 discharged patient records reviewed (#1, 2, 3, 4), and 1 of 1 active patient records reviewed (#5). Findings include: 1. An agency job description, revised December 2018 and titled "Job Title/Position: Registered Nurse," stated " ...The registered nurse plans, organizes, and directs hospice care ... Essential Job Functions/Responsibilities ... 3. Assesses and evaluates the patient's status by: A. Writing and initiating plan of care ... 4. Initiates the plan of care and makes necessary revisions as patient status and needs change" 2. The agency policy, revised December 2018 and titled "Ongoing Comprehensive Assessment," stated " ... Procedure ... 4. Based on the assessments, the plan of care - including problems, needs, goals, and outcomes - will be reviewed and updated ..." 3. The entire clinical record of Patient #1 for the benefit periods of 10/25/18 - 1/22/19 and 5/17/20 - 7/15/2020 was reviewed on 8/6/20, and indicated a discharge date of 5/21/20. The clinical record contained a plan of care for the benefit period of 5/17/2020 - 7/15/20, and the patient's diagnoses included but were not limited to ischemic cardiomyopathy (condition where the heart muscle is weakened), paroxysmal atrial fibrillation (an irregular heart rhythm that will start and stop on its own), heart failure, Essential hypertension (high blood pressure with no known cause), chronic obstructive pulmonary disease (COPD, a chronic respiratory condition), and acute kidney failure. The plan of care included "Interventions Ordered" identified, but not limited to, Bowel Elimination, Cardiovascular, Fall Prevention, Nutrition / Hydration, Pain, Respiratory, Skin Integrity, Sleep Patterns, Social Emotional Functioning, and Urinary Elimination, as patient problems. The interventions ordered failed to include updated, individualized interventions, as evidenced by: The "Bowel Elimination" interventions included "Bowel regimen per physician order and effectiveness," "Medication administration, side effects and response," "Patient/Caregiver to administer medications per MD order," and "Colace [stool softener] 100 mg [milligrams] BID [twice a day]; Miralax 17gm [grams] daily." The medication list on the plan of care failed to evidence the patient was currently taking Colace, Miralax, or any other medication used in a bowel regimen (stool softener, laxative, etc). The "Cardiovascular" interventions included "Patient/Caregiver to administer medications per MD order" and "Spironolactone [diuretic or water pill used in treatment for heart failure] 100mg daily, amiodarone [used for irregular heart rhythm] 150mg daily; Lasix [diuretic used in treatment for heart failure] 20 mg BID; Nitro [Nitroglycerin, used for chest pain] 0.4mg daily PRN [as needed] angina [chest pain]; torsemide [diuretic used in treatment for heart failure] 20mg daily." The medication list on the plan of care failed to evidence the patient was currently taking Spironolactone, Amiodarone, Lasix, Nitroglycerin, Torsemide, or any other medication related to the patient's history of cardiomyopathy, atrial fibrillation, heart failure, or hypertension. The "Fall Prevention" problem failed to include any interventions or specific protocols put into place. The "Nutrition / Hydration" interventions included "Medication administration, side effects, and response" and "Patient/Caregiver to administer medication per MD order," however the medication list on the plan of care failed to evidence the patient was currently taking any medications or other treatments for nutrition-related conditions. The "Pain" interventions included "Gabapentin [used for nerve pain] 400mg TID [three times a day]; Tramadol [medication used for pain] 50mg BID PRN; Tylenol [medication used for pain] 650mg Q6H [every 6 hours] PRN," however the medication list on the plan of care failed to evidence the patient was currently taking Gabapentin, Tramadol, and Tylenol. The "Respiratory" interventions included "Bensonatate [used to treat cough] 100 mg TID," however the medication list on the plan of care failed to evidence the patient was currently taking Bensonatate." The "Respiratory" interventions also included "May check O2 [oxygen] saturation [vital sign which measures the percentage of blood that is getting oxygenated, helps assess if a patient is not getting enough oxygen] per MD order," however the plan of care failed to indicate parameters for which the oxygen saturation level was to be reported. The "Skin Integrity" interventions included "Skin breakdown and prevention," however the interventions failed to evidence the specific precautions put into place. The interventions also included "Patient/Caregiver to administer medications per MD order," however the medication list on the plan of care failed to evidence the patient was currently taking any medication related to this problem. The "Sleep Patterns" interventions included "Medication administration, side effects, and response," and "Patient/Caregiver to administer medications per MD order," however the medication list on the plan of care failed to evidence the patient was currently taking any medication related to sleep issues. The "Social Emotional Functioning" intervention stated "Assess Patient/Caregiver's emotional functioning each visit thru 3/17/2020." This intervention was outdated, as the plan of care was for the certification period of 5/17/20 - 7/15/2020. The "Urinary Elimination" interventions included "Flomax [medication used for urinary and prostate issues] 0.4 mg daily" and "Patient/Caregiver to administer medications per MD order." The medication list included in the plan of care failed to evidence the patient was currently taking Flomax or any medications for urinary elimination issues. 4. The entire clinical record of Patient #2 for the benefit periods of 1/18/19 - 4/17/19, 4/18/19 - 7/16/19, 4/24/19 - 6/22/19, and 10/21/19 - 12/19/19 was reviewed on 8/6/20, and indicated a discharge date of 12/9/19. The clinical record included a plan of care for the benefit period of 10/21/19 - 12/19/19, and the patient's diagnoses included but were not limited to "Hemiplegia ... following cerebral infection [paralysis on one side of the body due to damage from a stroke]," Essential hypertension, Type 2 diabetes mellitus, history of kidney stones, and Gastro-esophageal reflux disease (GERD, a condition where stomach acid flows back into the esophagus and throat). The plan of care included "Interventions Ordered" identified, but not limited to, Bowel Elimination, Coping, Fall Prevention, Nutrition / Hydration, Physical Mobility, Psychological / Mental / Emotional, Respiratory, Skin Integrity, and Sleep Patterns as patient problems. The interventions ordered failed to include updated, individualized interventions, as evidenced by: The "Bowel Elimination" interventions included "Bowel regimen per physician order and effectiveness," and "Skin breakdown and prevention." The interventions failed to indicate the specific "bowel regimen" and skin breakdown precautions put into place. The "Coping" interventions included "Teach medication regime related to _x___ anxiety or _x_____ agitation [sic]," however the medication list failed to evidence the patient was currently taking medication for anxiety or agitation. The "Fall Prevention" problem failed to include any interventions or specific protocols put into place. The "Nutrition / Hydration" interventions included "Medication administration, side effects, and response" and "Patient/Caregiver to administer medication per MD order," however the medication list on the plan of care failed to evidence the patient was currently taking any medications or other treatments for nutrition-related conditions. The "Physical Mobility" interventions included "Safe transfers," "Basic personal care techniques and activities of daily living (ADLs)," and "Caregiver to administer medications per MD order." The interventions failed to indicate specific protocols put into place regarding patient transfers, personal care techniques, and ADLs. The medication list on the plan of care failed to evidence the patient was currently taking any medications or other treatments related to physical mobility issues. The "Psychological / Mental / Emotional" interventions included "Safety measures to prevent injury," however the interventions failed to indicate specific protocols put into place regarding safety measures. The "Respiratory" interventions included "caregiver to administer medications per MD order" and "May check O2 saturation per MD order." The plan of care failed to indicate the frequency of checking oxygen saturation levels and parameters for which the oxygen saturation level was to be reported. The medication list on the plan of care failed to evidence the patient was currently taking any medications or other treatments related to respiratory issues. The "Skin Integrity" interventions included "Skin breakdown and prevention," however the interventions failed to evidence the specific precautions put into place. The "Sleep Patterns" interventions included "Medication administration, side effects, and response," and "Patient/Caregiver to administer medications per MD order," however the medication list on the plan of care failed to evidence the patient was currently taking any medication related to sleep issues. 5. The entire clinical record of Patient #3 for the benefit period of 3/19/19 - 5/16/19 was reviewed on 8/6/20 and 8/7/20, and indicated a discharge date of 5/8/19. Patient #3's clinical record contained a plan of care for the benefit period of 3/19/19 -6/19/19, and indicated the patient's diagnoses included but were not limited to "Malignant neoplasm of ... right female breast [Breast cancer]" and "Malignant neoplasm of brain [Brain cancer]." The plan of care included "Interventions Ordered" identified, but not limited to, Bowel Elimination, Fall Prevention, Gastrointestinal, Nutrition / Hydration, Psychological / Mental / Emotional, and Skin Integrity as patient problems. The interventions ordered failed to include updated, individualized interventions, as evidenced by: The Gastrointestinal interventions included "Patient/Caregiver to administer medication per MD order," "Medication administration, side effects and response," "Nutritional changes and needs related to terminal illness," and "Risk of aspiration." The interventions failed to indicate specific protocols put into place regarding aspiration risk and nutritional changes and needs. The medication list on the plan of care failed to evidence the patient was currently taking medication for gastrointestinal issues. The "Psychological / Mental / Emotional" interventions included "Safety measures to prevent injury" and "Patient/Caregiver to administer medication per MD order." The interventions failed to indicate specific protocols put into place regarding safety measures, and the medication list on the plan of care failed to evidence the patient was currently taking medication for psychological, mental, or emotional issues. The "Bowel Elimination" interventions included "Bowel regimen per physician order and effectiveness," and "Skin breakdown and prevention." The interventions failed to indicate the specific "bowel regimen" and skin breakdown precautions put into place. The "Fall Prevention" problem failed to include any interventions or specific protocols put into place. The "Nutrition / Hydration" interventions included "Medication administration, side effects, and response" and "Patient/Caregiver to administer medication per MD order," however the medication list on the plan of care failed to evidence the patient was currently taking any medications or other treatments for nutrition-related conditions. The "Skin Integrity" interventions included "Skin breakdown and prevention," however the interventions failed to evidence the specific precautions put into place. 6. The entire clinical record of Patient #4 for the benefit period of 6/22/2109 - 9/19/2019 was reviewed on 8/7/2020, and indicated a hospice discharge date of 7/8/19. Patient #4's clinical record contained a plan of care for the benefit period of 6/22/2109 - 9/19/2019, and indicated the patient's diagnoses included but were not limited to heart failure, chronic kidney disease, dementia, and atrial fibrillation. The plan of care included "Interventions Ordered" identified, but not limited to, Bowel Elimination, Cardiovascular, Fall Prevention, Pain, Physical Mobility, Psychological / Mental / Emotional, Respiratory, Skin Integrity, and Urinary Elimination as patient problems. The interventions ordered failed to include updated, individualized interventions, as evidenced by: The Bowel Elimination interventions included "Bowel regimen per physician order and effectiveness," "S/S [Signs and symptoms, sic] Fleet enema [laxative injected into the rectum to treat constipation] PRN constipation," and "Other." The interventions failed to indicate specific protocols put into place for the bowel regimen, the medication list failed to evidence the patient currently had an order for a fleet enema, and the "Other" intervention failed to include further detail regarding the intervention. The Cardiovascular interventions included "Edema, fluid retention and dehydration," but failed to indicate the protocols put into place regarding this intervention. The Pain interventions included "Facility nurse to administer medication per MD order," however that medication list on the plan of care failed to evidence the patient was currently taking medication for pain. The "Psychological / Mental / Emotional" interventions included "Safety measures to prevent injury" and "Facility nurse to administer medications per MD order." The interventions failed to indicate specific protocols put into place regarding safety measures, and the medication list in the plan of care failed to evidence the patient was currently taking medication for a psychological, mental, or emotional issue. The "Respiratory" interventions also included "Facility nurse to administer medication per MD order" and "May check O2 saturation per MD order." The medication list on the plan of care failed to evidence the patient was currently taking medication for a respiratory issue, and plan of care failed to indicate parameters for which the oxygen saturation level was to be reported. The "Skin Integrity" interventions included "Skin breakdown and prevention" and "Patient/Caregiver to administer medications per MD order." The interventions failed to evidence the specific precautions put into place for skin breakdown and prevention, and the medication list on the plan of care failed to evidence the patient was currently taking any medication related to skin integrity. The "Skin Integrity" interventions also included "Wound care as follows: Cleanse with normal saline, pat dry. Apply medihoney gel [topical ointment used for wound care] and cover with foam dressing. Change daily and prn soilage. Staff to change when hospice nurse not present," The intervention failed to indicate the location of the wound to be treated, and the medication list on the plan of care failed to evidence the patient had an active order for medihoney gel. The "Fall Prevention" problem failed to include any interventions or specific protocols put into place. The "Physical Mobility" interventions included "Safe transfers," "Basic personal care techniques and activities of daily living (ADLs)," and "Caregiver to administer medications per MD order." The interventions failed to indicate specific protocols put into place regarding patient transfers, personal care techniques, and ADLs. The medication list on the plan of care failed to evidence the patient was currently taking any medications or other treatments related to physical mobility issues. 7. The entire clinical record of Patient #5, for the benefit period of 6/25/20 - 9/22/20, was reviewed on 8/7/2020, and indicated a hospice election date of 6/25/2020. Patient #5's clinical record contained a plan of care for the benefit period of 6/25/20 - 9/22/20, and indicated the patient's diagnoses included but were not limited to "Cerebral infarction due to ... occlusion or stenosis of ... cerebellar artery," (death of brain tissue caused by a blockage or narrowing of an artery in the brain), Essential hypertension, traumatic brain injury, COPD, and Type 2 diabetes mellitus. The plan of care included "Interventions Ordered" identified, but not limited to, Bowel Elimination, Cardiovascular, Fall Prevention, Nutrition / Hydration, Physical Mobility, Psychological / Mental / Emotional, Respiratory, and Skin Integrity as patient problems. The interventions ordered failed to include updated, individualized interventions, as evidenced by:' The intervention of "Bowel Elimination" included "Bowel regimen per physician order and effectiveness," "Medication administration, side effects and response," "Skin breakdown and prevention," and "Patient/Caregiver to administer medications per MD order." The interventions failed to indicate the protocols and precautions put into place for "bowel regimen" and skin breakdown. The medication list on the plan of care failed to indicate the patient was currently taking any medication for a bowel elimination issue. The "Respiratory" intervention included "May check O2 saturation per MD order," however the plan of care failed to indicate parameters for which the oxygen saturation level was to be reported. The Cardiovascular interventions included "Edema, fluid retention and dehydration," but failed to indicate the protocols put into place regarding this intervention. The "Fall Prevention" problem failed to include any interventions or specific protocols put into place. The "Nutrition / Hydration" interventions included "Medication administration, side effects, and response" and "Patient/Caregiver to administer medication per MD order," however the medication list on the plan of care failed to evidence the patient was currently taking any medications or other treatments for nutrition-related conditions. The "Physical Mobility" interventions included "Safe transfers," "Basic personal care techniques and activities of daily living (ADLs)," and "Caregiver to administer medications per MD order." The interventions failed to indicate specific protocols put into place regarding patient transfers, personal care techniques, and ADLs. The medication list on the plan of care failed to evidence the patient was currently taking any medications or other treatments related to physical mobility issues. The "Psychological / Mental / Emotional" interventions included "Safety measures to prevent injury," however the interventions failed to indicate specific protocols put into place regarding safety measures. 8. The administrator and Director of Compliance were notified of the preliminary concern on 8/7/20 at 4:55 PM, and declined to provide any further evidence or documentation.
L0548
L0548	42617 Based on record review and interview, the hospice agency failed to ensure the plan of care contained specific, individualized, and measurable outcomes for patient and/or caregiver goals for 4 of 5 discharged patient records reviewed (#1, 2, 3, 4), and 1 of 1 active patient records reviewed (#5). Findings include: 1. An agency job description, revised December 2018 and titled "Job Title/Position: Registered Nurse," stated " ...Essential Job Functions/Responsibilities ... Develops a care plan that establishes goals, based on nursing diagnosis ..." 2. The entire clinical record of Patient #1 for the benefit periods of 10/25/18 - 1/22/19 and 5/17/20 - 7/15/2020 was reviewed on 8/6/20, and indicated a discharge date of 5/21/20. The clinical record contained a plan of care for the benefit period of 5/17/2020 - 7/15/20, and the patient's diagnoses included but were not limited to ischemic cardiomyopathy (condition where the heart muscle is weakened), paroxysmal atrial fibrillation (an irregular heart rhythm that will start and stop on its own), heart failure, Essential hypertension (high blood pressure with no known cause), chronic obstructive pulmonary disease (COPD, a chronic respiratory condition), and acute kidney failure. The plan of care identified patient goals including, but not limited to bowel elimination, cardiovascular, coping, grief issues, nutrition / hydration, pain, physical mobility, respiratory, skin integrity, and sleep patterns. The patient and/or caregiver goals failed to evidence specific, individualized, and measurable outcomes as evidenced by: The bowel elimination goal indicated the "patient/caregiver will demonstrate ability to manage bowel routine," but failed to evidence specifically what a "normal" or "optimal" bowel routine was for the patient. The coping goal indicated " ___ Ability to express feelings and concerns" but failed to evidence who the goal was regarding (patient, caregiver, etc). The grief issues goal indicated "Patient/caregiver will achieve optimal grief reaction," but failed to evidence specifically what a normal or optimal grief reaction was for the patient and caregiver. The nutrition / hydration goal indicated "Promote optimal nutrition/hydration during care," but failed to evidence specifically what the normal or optimal nutrition and hydration was for the patient. The pain goal indicated "Patient's pain will remain at comfortable level" and "Patient will receive optimal level of pain and/or symptom management," but failed to indicate the specific range or pain goal the patient considered comfortable or optimal, as well as the range or goal for symptom management. The physical mobility goal indicated "Patient will maintain optimal mobility" and "Optimal hygiene will be maintained during care," but failed to indicate specifically what was normal or optimal mobility and hygiene for the patient. The respiratory goal indicated "Patient respiratory status will be maintained at optimal level," but failed to indicate specifically what a normal or optimal respiratory status was for the patient. The sleep patterns goal indicated "Patient will achieve optimal sleep/rest during care," but failed to indicate specifically what normal or optimal sleep and rest was for the patient. The skin integrity goal indicated "skin will be maintained at optimal level," but failed to evidence specifically what a normal or optimal skin level was for the patient. The cardiovascular and respiratory goals also failed to indicate a specific vital sign to achieve to maintain the patient's quality of life. 3. The entire clinical record of Patient #2 for the benefit periods of 1/18/19 - 4/17/19, 4/18/19 - 7/16/19, 4/24/19 - 6/22/19, and 10/21/19 - 12/19/19 was reviewed on 8/6/20, and indicated a discharge date of 12/9/19. The clinical record included a plan of care for the benefit period of 10/21/19 - 12/19/19, and the patient's diagnoses included but were not limited to "Hemiplegia ... following cerebral infection [paralysis on one side of the body due to damage from a stroke]," Essential hypertension, Type 2 diabetes mellitus, history of kidney stones, and Gastro-esophageal reflux disease (GERD, a condition where stomach acid flows back into the esophagus and throat). The plan of care identified patient goals including, but not limited to bowel elimination, cardiovascular, coping, grief issues, nutrition / hydration, pain, physical mobility, respiratory, skin integrity, and sleep patterns. The patient and/or caregiver goals failed to evidence specific, individualized, and measurable outcomes as evidenced by: The bowel elimination goal indicated the "patient/caregiver will demonstrate ability to manage bowel routine," but failed to evidence specifically what a "normal" or "optimal" bowel routine was for the patient. The coping goal indicated " ___ Ability to express feelings and concerns" but failed to evidence who the goal was regarding (patient, caregiver, etc). The grief issues goal indicated "Patient/caregiver will achieve optimal grief reaction," but failed to evidence specifically what a normal or optimal grief reaction was for the patient and caregiver. The nutrition / hydration goal indicated "Promote optimal nutrition/hydration during care," but failed to evidence specifically what the normal or optimal nutrition and hydration was for the patient. The pain goal indicated "Patient's pain will remain at comfortable level" and "Patient will receive optimal level of pain and/or symptom management," but failed to indicate the specific range or pain goal the patient considered comfortable or optimal, as well as the range or goal for symptom management. The physical mobility goal indicated "Patient will maintain optimal mobility" and "Optimal hygiene will be maintained during care," but failed to indicate specifically what was normal or optimal mobility and hygiene for the patient. The respiratory goal indicated "Patient respiratory status will be maintained at optimal level," but failed to indicate specifically what a normal or optimal respiratory status was for the patient. The sleep patterns goal indicated "Patient will achieve optimal sleep/rest during care," but failed to indicate specifically what normal or optimal sleep and rest was for the patient. The skin integrity goal indicated "skin will be maintained at optimal level," but failed to evidence specifically what a normal or optimal skin level was for the patient. The cardiovascular and respiratory goals also failed to indicate a specific vital sign to achieve to maintain the patient's quality of life. The plan of care failed to indicate a goal which specified a blood sugar range to achieve to maintain the patient's quality of life. 4. The entire clinical record of Patient #3 for the benefit period of 3/19/19 - 5/16/19 was reviewed on 8/6/20 and 8/7/20, and indicated a discharge date of 5/8/19. Patient #3's clinical record contained a plan of care for the benefit period of 3/19/19 -6/19/19, and indicated the patient's diagnoses included but were not limited to "Malignant neoplasm of ... right female breast [Breast cancer]" and "Malignant neoplasm of brain [Brain cancer]." The plan of care identified patient goals including, but not limited to advanced planning, bowel elimination, coping, gastrointestinal, nutrition / hydration, pain, psychosocial/mental/emotional, and skin integrity. The patient and/or caregiver goals failed to evidence specific and individualized outcomes as evidenced by: The advanced planning goal indicated "assess for advance directives and funeral arrangements," but did not specifically indicate what the patient was needing to work towards for advance directives and funeral arrangements (were the advance directives needing to be completed or changed, was the patient just to determine funeral home or make all funeral arrangements, etc.). The gastrointestinal goal indicated "patient's nausea/vomiting will be controlled," but failed to indicate the specific range or vomiting/nausea goal the patient considered the symptom to be controlled (example: Nausea remains at or below a 5 on a 0 -10 scale, only 1 episode of vomiting per day, etc). The psychological/mental/emotional goal indicated "Patient's agitation will be controlled to a manageable level," but failed to evidence specifically what a normal and manageable level of agitation was for the patient. The bowel elimination goal indicated the "patient/caregiver will demonstrate ability to manage bowel routine," but failed to evidence specifically what a "normal" or "optimal" bowel routine was for the patient. The coping goal indicated " ___ Ability to express feelings and concerns" but failed to evidence who the goal was regarding (patient, caregiver, etc). The grief issues goal indicated "Patient/caregiver will achieve optimal grief reaction," but failed to evidence specifically what a normal or optimal grief reaction was for the patient and caregiver. The pain goal indicated "Patient's pain will remain at comfortable level" and "Patient will receive optimal level of pain and/or symptom management," but failed to indicate the specific range or pain goal the patient considered comfortable or optimal, as well as the range or goal for symptom management. The skin integrity goal indicated "skin will be maintained at optimal level," but failed to evidence specifically what a normal or optimal skin level was for the patient. 5. The entire clinical record of Patient #4 for the benefit period of 6/22/2109 - 9/19/2019 was reviewed on 8/7/2020, and indicated a hospice discharge date of 7/8/19. Patient #4's clinical record contained a plan of care for the benefit period of 6/22/2109 - 9/19/2019, and indicated the patient's diagnoses included but were not limited to heart failure, chronic kidney disease, dementia, and atrial fibrillation. The plan of care identified patient goals including, but not limited to advanced planning, bowel elimination, grief issues, pain, physical mobility, respiratory, and skin integrity. The patient and/or caregiver goals failed to evidence specific, individualized, and measurable outcomes as evidenced by: The bowel elimination goal indicated the "patient/caregiver will demonstrate ability to manage bowel routine," but failed to evidence specifically what a "normal" or "optimal" bowel routine was for the patient. The grief issues goal indicated "Patient/caregiver will achieve optimal grief reaction," but failed to evidence specifically what a normal or optimal grief reaction was for the patient and caregiver. The pain goal indicated "Patient's pain will remain at comfortable level" and "Patient will receive optimal level of pain and/or symptom management," but failed to indicate the specific range or pain goal the patient considered comfortable or optimal, as well as the range or goal for symptom management. The physical mobility goal indicated "Patient will maintain optimal mobility" and "Optimal hygiene will be maintained during care," but failed to indicate specifically what was normal or optimal mobility and hygiene for the patient. The skin integrity goal indicated "skin will be maintained at optimal level," but failed to evidence specifically what a normal or optimal skin level was for the patient. The cardiovascular and respiratory goals also failed to indicate a specific vital sign to achieve to maintain the patient's quality of life. The respiratory goal indicated "Patient respiratory status will be maintained at optimal level," but failed to indicate specifically what a normal or optimal respiratory status was for the patient. The advanced planning goal indicated "assess for advance directives and funeral arrangements," but did not specifically indicate what the patient was needing to work towards for advance directives and funeral arrangements (were the advance directives needing to be completed or changed, was the patient just to determine funeral home or make all funeral arrangements, etc.). The gastrointestinal goal indicated "patient's nausea/vomiting will be controlled," but failed to indicate the specific range or vomiting/nausea goal the patient considered the symptom to be controlled (example: Nausea remains at or below a 5 on a 0 -10 scale, only 1 episode of vomiting per day, etc). The psychological/mental/emotional goal indicated "Patient's agitation will be controlled to a manageable level," but failed to evidence specifically what a normal and manageable level of agitation was for the patient. 6. The entire clinical record of Patient #5, for the benefit period of 6/25/20 - 9/22/20, was reviewed on 8/7/2020, and indicated a hospice election date of 6/25/2020. Patient #5's clinical record contained a plan of care for the benefit period of 6/25/20 - 9/22/20, and indicated the patient's diagnoses included but were not limited to "Cerebral infarction due to ... occlusion or stenosis of ... cerebellar artery," (death of brain tissue caused by a blockage or narrowing of an artery in the brain), Essential hypertension, traumatic brain injury, COPD, and Type 2 diabetes mellitus. The plan of care identified patient goals including, but not limited to bowel elimination, cardiovascular, endocrine, nutrition/hydration, pain, physical mobility, respiratory, skin integrity, and sleep patterns. The patient and/or caregiver goals failed to evidence specific, individualized, and measurable outcomes as evidenced by: The endocrine goal stated "Patient/caregiver understands and administers proper diabetic care," but failed to evidence specifically what proper diabetic care was for the patient, or give a blood sugar range to achieve to maintain the patient's quality of life. The bowel elimination goal indicated the "patient/caregiver will demonstrate ability to manage bowel routine," but failed to evidence specifically what a "normal" or "optimal" bowel routine was for the patient. The nutrition / hydration goal indicated "Promote optimal nutrition/hydration during care," but failed to evidence specifically what the normal or optimal nutrition and hydration was for the patient. The pain goal indicated "Patient's pain will remain at comfortable level" and "Patient will receive optimal level of pain and/or symptom management," but failed to indicate the specific range or pain goal the patient considered comfortable or optimal, as well as the range or goal for symptom management. The physical mobility goal indicated "Patient will maintain optimal mobility" and "Optimal hygiene will be maintained during care," but failed to indicate specifically what was normal or optimal mobility and hygiene for the patient. The respiratory goal indicated "Patient respiratory status will be maintained at optimal level," but failed to indicate specifically what a normal or optimal respiratory status was for the patient. The sleep patterns goal indicated "Patient will achieve optimal sleep/rest during care," but failed to indicate specifically what normal or optimal sleep and rest was for the patient. The skin integrity goal indicated "skin will be maintained at optimal level," but failed to evidence specifically what a normal or optimal skin level was for the patient. 7. An interview with the administrator was conducted on 8/7/2020 at 3:45 PM. During the interview, the administrator indicated all patient goals should be measurable.