Every finding on record at 702 Hospice Corp

Observed in Record Review. In 7 of 10 active patient records reviewed, the organization failed to ensure the plan of care was updated based on the patient’s reassessment and progress toward goals. In RRNHV #1, the plan of care had not been updated to reflect the current assessment, achieving goals that had been achieved. For example, patient has been on service since 2023 there is patient teaching goals that have not been achieved in those two years. In RRNHV #2, it was noted that patient had complaints of dry eyes and was receiving medication for the dry eyes but there was no goals to reflect this problem. In RRNHV #3, it was noted that the patient had Nystop powder started but the Plan of Care was not updated to reflect this new therapy. In RRHV #3, RRNHV #4 and RRNHV #5 it was noted that patient has been on service for several benefit periods and still has teaching goals from admission. On RRNHV #6 it was noted that the patient was started on an antibiotic, but the plan of care was not updated to reflect this change. This finding was reviewed with hospice leadership.

Observed in Record Review. In 1 of 10 active patient record reviews, documentation in the patient record is not entered timely. Agency policy is that documentation is completed within 3 days and in the medical record. On RRNHV #5, the nursing documentation has not been completed for the last three weeks, the agency has had some EMR issues but had not implemented the requirement for paper documentation during the down to meet the agency policy. This finding was reviewed and validated agency leadership.

Observed in Record Review. In 7 out of 10 patient records reviewed, the goals established on the plan of care were not measurable and specific. On RRNHV #1, it was noted that goals were not measurable and specific to the patient. For example, “Pt will maintain optimum peripheral circulation”, “Facilitate bowel elimination and comfort”. On RRNHV #2 it was noted that goals were not measurable and specific to the patient with example of Keep pain below SIT level for comfort. On RRNHV #4 it was noted that goals were not measurable and specific with an example of “Facilitate bowel elimination and comfort”. On RRNHV #6 and RRNHV #7 it was noted that goals were not specific and measurable with an example of “Maintain BP levels within normal limits”. On RRHV #2 it was noted that goals were not measurable and specific to the patient with an example of “Optimal bowel elimination and comfort”. On RRHV #3, goals were not measurable with the example of “Achieve and maintain peripheral circulation for Pt comfort”. This finding was reviewed with hospice leadership.

Observed in Record Review. In 2 of 14 active patient records reviewed, the hospice nurse surveyor noted medication orders were not clear and accurate. On RRNHV # 4 there was duplicate PRN medications for constipation, Senna PRN for constipation and Bisacodyl Suppository PRN for constipation and no indication how to handle the duplicate therapies. On RRNHV #5 it was noted that patient had multiple PRN constipation, Lactulose and Bisacodyl, there is no clear indication when to both duplicate therapies. This finding was reviewed with hospice leadership.

Observed in Patient Home. In 2 of 3 home visits conducted, the nurse surveyor observed that the agency did not implement measures to reduce the risk of infection associated with medical equipment. Agency Bag Technique policy (9-014.1) states that equipment will be cleaned with alcohol and/or soap and water. On RRHV #1, the nurse did not follow agency policy, he cleaned her vital sign equipment with Handiwipes to clean equipment and the manufacturer guidelines for use is hand cleaning not equipment. On RRHV #3, the nursed cleaned his vital sign equipment with Clorox and did not follow the manufacturer wet time of 3 minutes prior to returning equipment back to bag. This finding was reviewed with agency leadership.

Observed in Tracer Activities. Identified during the review of the Volunteer Program, the 5 percent of the total patient care hours requirement was not achieved. Year to date for 2025 the agency is only at 1.3% for their volunteer hours. For 2025 the agency was at 4.5% for the year. Agency does have an active plan to improve the rates. This was reviewed with agency leaders.

Observed in Individual Tracer. In 4 of 4 patient records reviewed, and confirmed by the RN case manager and DON, the plan of care had not reflected measurable goals pertinent to the findings. All goals had been documented to be resolved at end of certification period. Example: During review of HOSrr#2 the goal had documented that the patient caregiver will verbalize understanding of medications by end of certification. Review of HOSrr#3 all goals had been documented to be resolved by end of certification to include pain in right heel.

Observed in Record Review. In 4 of 11 patient records reviewed, the surveyor found that the initial bereavement assessment had not been completed. For example, in HV1, RR1 and RR7, the assessment was present but did not identify a bereaved. In HV3, there was no bereavement assessment completed as required by Policy: Initial Assessment/Comprehensive assessment pg 9.6.2. This was discussed with the Administrator/DPCS, the Alternate Administrator and the Alternate DPCS.

Observed in Record Review. In 3 of 11 patient records reviewed, the surveyor found that the plan of care was not specific for care and services identified in the comprehensive assessment. For example, in review of the medical record for HV1, HV2 and HV3, the patient was identified with a problem for imminent death but patient was not assessed as being imminent at time of admission. This was discussed with the Administrator/DPCS, the Alternate Administrator and the Alternate DPCS.

Observed in Record Review. In 11 of 11 patient records reviewed, the surveyor found that the organization had not specified consistently measurable outcomes for each of the problems identified in the comprehensive assessment of the patient. For example in HV1, outcomes included the following- Patient will maintain optimum peripheral circulation; Optimal blood sugar management for patient comfort; Facilitate optimal bowel movement. In HV3, outcomes included the following- Patient will maintain optimum peripheral circulation; Optimal blood sugar management for patient comfort. In RR2, outcomes included the following- Patient will maintain optimum peripheral circulation; Verbalize having urinary elimination needs met at an acceptable level; Maintain optimal mobility and independence. Similar outcome were found for HV2, RR1, RR3, RR4, RR5, RR6, RR7, and RR8. This was discussed with the Administrator/DPCS, the Alternate Administrator and the Alternate DPCS.

Observed in Record Review. In 11 of 11 patient records reviewed, the surveyor found that the organization had not consistently specified the frequency of services to be provided. For example, in review of the medical record for HV1, HV2, HV3, RR1, RR2, RR3, RR4, RR5, RR6, RR7, and RR8, the frequency of services provided included PRN visits by the RN, MSW and SC. These PRN visits did not consistently specify the number of PRN visits that could be completed. This was discussed with the Administrator/DPCS, the Alternate Administrator and the Alternate DPCS.

Observed in Record Review. In 10 of 11 patient records reviewed, the hospice surveyor noted that the organization had not specified the unique medications and treatments necessary to meet the patient's needs. For example, in HV1, the patient had Hydrocodone/acetaminophen, Morphine Sulfate IR and Acephen ordered as needed for pain without further defining when each one should be taken. In HV3, RR1, RR2, RR3, RR4, RR5, RR6, RR7, and RR8, the patient had Morphine Sulfate IR and Acephen ordered as needed for pain without further defining when each one should be taken. This was discussed with the Administrator/DPCS, the Alternate Administrator and the Alternate DPCS.

Observed in Patient Home. In 1 of 3 home visits conducted, the surveyor observed that the staff member did complete hand hygiene when required. For example, during the home visit for HV2, the staff member changed his gloves multiple times during provision of care and did not perform hand hygiene between doffing and donning. He was also observed replacing items into his bag without first removing contaminated gloves and performing hand hygiene. This was discussed with the Administrator/DPCS, the Alternate Administrator and the Alternate DPCS. Observed in Patient Home. In 1 of 3 home visits conducted, the surveyor observed the staff member clean his glucometer with a Bactive (quintenary ammonia) cleaning wipe. In review of the manufacturer's instructions, the device was only to be cleaned with a damp cloth. This was discussed with the Administrator/DPCS, the Alternate Administrator and the Alternate DPCS.

Observed in HR File Review. In 6 of 7 HR files reviewed, for core staff members, the surveyor found that the staff members were 1099 contracted employees. This was found for HR1, HR2, HR3, HR5, HR8, and HR9. This was discussed with the Administrator/DPCS, the Alternate Administrator and the Alternate DPCS.

Observed in HR File Review. In 1 of 2 HR files reviewed, for the hospice aide, the surveyor found that the initial competency had not been performance with patient or a pseudo patient. For example, in review of the HR file for HR6 and discussion with the registered nurse evaluating performance, the RN stated that his initial competency had been verbal.

Observed in Record Review. In 8 of 9 patient records reviewed, where the patient had hospice aide services ordered, the surveyor found that the plan of care was not specific for the tasks the aide was to perform and/or the registered nurse had not provided the aide with information on safety precautions to implement and/or when to notify the nurse. For example, in HV1, HV2, RR1, RR2, RR3, RR4, RR7, and RR8, the aide was to obtain vital signs and/or perform range of motion with the patient. There were no vital sign parameters identified for the aide to use to report variances and there were no instructions to report variances. Range of motion had not been specified as active or passive. In addition, RR3 and RR4 had Eliquis prescribed and the aide was not provided with information on safety precautions to implement and/or when to notify the nurse related to this medication. This was discussed with the Administrator/DPCS, the Alternate Administrator and the Alternate DPCS.

Observed in Tracer Activities. In 4 of 9 patient records reviewed, where the patient had hospice aide services ordered, the surveyor noted that the aide had not provided services as required. For example, during the home visit for HV2, the patient was to receive assistance with a shower with chair, mouth care and nail care. The aide stated prior to the visit he only assists the patient with passive range of motion and obtains her vital signs. This was confirmed by the family member who stated they provide the patient's personal care. In review of the medical record for RR1, RR3, and RR6, the aide was obtaining and documenting a pulse oximetry reading, Pulse oximetry was not part of the care plan for the aide to complete. This was discussed with the Administrator/DPCS, the Alternate Administrator and the Alternate DPCS.

Observed in Record Review. In 1 of 9 patient records reviewed, where the patient had hospice aide services ordered, the surveyor found that supervisory visits were not completed every 14 days. For example, in review of the medical record for RR8, there were three occasions where aide supervision was completed at greater than 14 days. This was discussed with the Administrator/DPCS, the Alternate Administrator and the Alternate DPCS.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: - §418.100, §418.56, §418.76, §418.64 and §418.116

Observed in HR File Review. In 1 of 10 HR files reviewed, the surveyor did not find evidence of ongoing competency assessment. For example, in HR5, the staff member held both the position of Spiritual Counselor and Bereavement Coordinator. The position of Bereavement Coordinator did not have evidence of ongoing competency evaluation. This was discussed with the Administrator/DPCS, the Alternate Administrator and the Alternate DPCS. Observed in HR File Review. In 1 of 10 HR files reviewed, the surveyor found that the organization had not assessed for initial competency. For example, fir HR5, initial competency had not been assessed for his role as bereavement coordinator. This was discussed with the Administrator/DPCS, the Alternate Administrator and the Alternate DPCS.

Observed in Record Review. In 3 of 11 patient records reviewed, the surveyor found that the documentation in the medical record was not accurate. For example, in review of the medical record for HV2, the surveyor noted that the aide documented he was completing all tasks as required by the aide plan of care. During the home visit the aide stated he did not complete the patient's personal care (shower chair, mouth care, nail care, etc) only range of motion and vital signs. During the home visit for HV3, during the review of the medications, it was found that the medication profile did not contain all the medications the patient was using. For example, Diclofenac sodium, Maalox and iron tablets were not on the medication profile. In review of the medical record for RR5, the patient's height was listed as 5 inches and BMI was 4,218 on admission and multiple notes.

Observed in Record Review. In 10 of 11 patient records reviewed, the surveyor found that multiple documents were signed and in the chart but were not complete. For example, in HV1 and HV2, the Informed Consent and Treatment Authorization, which collected information on advanced directives, was signed but not completed. Additionally, the Patient Acknowledgment form which documented education provided on home safety and execution of an advanced directive had been signed but not completed. In RR1, RR2, RR3, RR4, RR5, RR6, RR7 and RR8, one or both of these documents had also not been completed. In discussion with the alternate DPCS, she stated that the information had been discussed with family but that the DocuSign platform did not consistently allow for completion of the form, only the signature.

Observed in Tracer Activities. In 2 of 9 patient records reviewed, where oxygen had been ordered, the surveyor did not find where home oxygen safety teaching had been completed. For example, during the home visit for HV3, when asked about safety teaching that had been provided by the organization (caregiver stated she had a gas stove), she stated she had not received any information other that the patient could use it if she felt short of breath and how to turn it on and adjust the liter flow rate. This interaction was observed by the staff member performing the visit. In review of the medical record for RR8, there was no documentation that the patient had been provided with information related home oxygen safety based on assessed needs as no risk assessment had been completed. This was discussed with the Administrator/DPCS, the Alternate Administrator and the Alternate DPCS.

Observed in Tracer Activities. During the home visit for HV1, the surveyor observed the staff member use his personal glucometer to check the patient's blood glucose. The caregiver stated that the other nurse that visits the patient also completes a blood glucose check with her glucometer. The DPCS had previously stated that the organization did not perform blood glucose monitoring and so did not have a CLIA waiver. She confirmed after the visit that the organization did not have a CLIA waiver for blood glucose testing.