Every finding on record at Abc Hospice, LLC

Upon patient record review, 4 of 14 (Patient #2,3,5,9) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 2: The medical record indicated that the patient uses a wheelchair and Hoyer lift due to altered mobility and muscle weakness. No evidence of problems, interventions, and goals related to altered mobility included in the plan of care. Corrected on site. New order written to update the plan of during survey. Patient 3: The medical record indicated that the patient uses a wheelchair, has contractures in her neck and spine. No evidence of problems, interventions, and goals related to altered mobility included in the plan of care. Corrected on site. New order written to update the plan of during survey. Patient 5: Pre-bereavement risk assessment was completed by the nurse at the time of admit (04/10/2025) and was scored as high. Another bereavement risk assessment was completed by the chaplain on 04/10/2025 that also scored high. No evidence that a follow-up was completed or that anything was done to start supporting the caregiver. No evidence that the admitting nurse or chaplain communicated the high pre-bereavement risk with the rest of the team. No evidence that the bereavement care plan was updated to reflect the caregivers needs. Patient 9: Pre-bereavement risk assessment was completed by the nurse at the time of admit and was scored as moderate. Another bereavement risk assessment was completed by the chaplain on 08/04/2025 that also scored moderate. No evidence that a follow-up was completed or that anything was done to start supporting the caregiver. No evidence that the admitting nurse or chaplain communicated the high pre-bereavement risk with the rest of the team. No evidence that the bereavement care plan was updated to reflect the caregivers needs.

Upon client record review, 1 of 14 (Patient #2) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient 2: The medical record show that patient choose an attending physician at the time of admit. No evidence that IDG was conducted in collaboration with the attending physician at the time of survey.

Upon client record review, 3 of 14 (Patient #6,8,9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 6: RN documentation on 10/06/2025 indicated that she removed 6 staples from the patients head. No evidence that an order was received to remove the staples. Patient 8: The current plan of care has orders for volunteer visits to be completed 4 times a month starting in October 2025. No evidence that 4 visits occurred for the month of November 2025. Patient 9: The plan of care has orders for SN at 2 times a week. No evidence that 2 visits occurred for the week of 12/21/2025. One documented visits noted for the week.

Upon patient record review 2 of 14 (Patient #5,9) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient 5: Pre-bereavement risk assessment was completed by the nurse at the time of admit (04/10/2025) and was scored as high. Another bereavement risk assessment was completed by the chaplain on 04/10/2025 that also scored high. No evidence that a follow-up was completed or that anything was done to start supporting the caregiver. No evidence that the admitting nurse or chaplain communicated the high pre-bereavement risk with the rest of the team and that care and services were being addressed to meet patient/family needs. Patient 9: Pre-bereavement risk assessment was completed by the nurse at the time of admit and was scored as moderate. Another bereavement risk assessment was completed by the chaplain on 08/04/2025 that also scored moderate. No evidence that a follow-up was completed or that anything was done to start supporting the caregiver. No evidence that the admitting nurse or chaplain communicated the high pre-bereavement risk with the rest of the team and that care and services were being addressed to meet patient/family needs.

Upon patient record review 2 of 14 (Patient #6,8) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 6: Plan of care has aide frequency ordered as 2 times weekly. No evidence that the patient received 2 visits for the week of 10/12/25. No evidence that the visit was missed at the request of the patient/CG or that an order was received to decrease the amount of visits for the week. Patient 8: Plan of care has aide frequency ordered as 2 times weekly. No evidence that the patient received 2 visits for the week of 10/12/25 and the week10/26/2025. No evidence that these visits were missed at the request of the patient/CG or that an order was received to decrease visits for the week.

Upon patient record review 1 of 14 (Patient #2) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 2: No evidence that a registered nurse made a supervised visit every 14 days between 11/18/2025-12/09/2025 (21 days) and again between 12/09/2025 and 01/02/2025 (23 days).

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The agency did not utilize at least 5% of the total patient care hours in 2025. The total usage of volunteers for 2025 was 1.98%

Upon client record review, 2 of 14 (Patient #1,2) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. accordance with this hospice plan of care. Patient 1: The plan of care has orders for SN at 3 times a week. No evidence that 3 visits occurred for the week of 12/21/2025. Two documented visits noted for the week. Patient 2: The current plan of care has orders for volunteer visits to be completed 4 times a month for the month of October, twice a month for the month of November, then once for the month of December. No evidence that 4 visits were completed for the month of October, 2 visits for the month of November, nor one visit for the month of December.

Upon patient record review, 4 of 11 (Patients #2,#8,#10,#11) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient 2: The medication profile contained oxygen with no delivery method. Corrected on site. Patient 8: The care plan indicated patient use of oxygen equipment and problems, goals, and interventions related to oxygen use. There was no evidence of oxygen on the medication profile. Corrected on site. Patient 10: The care plan indicated patient use of oxygen equipment and problems, goals, and interventions related to oxygen use. There was no evidence of oxygen on the medication profile. Patient 11: The medication profile contained oxygen with no delivery method and polyethylene glycol oral powder with no instructions for a diluent.

Upon patient record review, 3 of 11 (Patients #2,#4,#8) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 2: The care plan contained problems of altered nutrition and respiratory function. There was no evidence of goals and interventions related to the problems. Corrected on site. The medical record contained a social work assessment and ordered social work frequency of once for first month, twice the second month, and three times the third month. There was no evidence of problems, goals, and interventions related to social work visits. Patient 4: The care plan contained problems of altered cardiac and respiratory function. There was no evidence of goals and interventions related to the problems. Corrected on site. Patient 8: The medical record contained nursing documentation 12/31/22 identifying increased patient difficulty with swallowing. There was no evidence of problems, goals, and interventions related to dysphagia. Corrected on site.

Upon patient record review, 4 of 11 (Patients #2,#8,#10,#11) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 2: The medical record contained an order for oxygen with no delivery method. Corrected on site. Patient 8: The care plan indicated patient use of oxygen equipment and problems, goals, and interventions related to oxygen use. There was no evidence of an order for oxygen with dose, frequency and delivery method included in the medical record. The care plan and nursing documentation also indicated patient had an indwelling catheter. There was no evidence of an order for catheter type, size, maintenance, and change frequency. Corrected on site. Patient 10: The care plan indicated patient use of oxygen equipment and problems, goals, and interventions related to oxygen use. There was no evidence of an order for oxygen with dose, frequency and delivery method included in the medical record. Patient 11: The medical record contained a orders for oxygen with no delivery method and polyethylene glycol oral powder with no instructions for a diluent. The care plan and nursing documentation also indicated patient had an indwelling catheter. There was no evidence of an order for catheter type, size, maintenance, and change frequency.

Upon client record review, 1 of 11 (Patient #8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 8: The medical record contained nursing documentation 12/27/22 identifying the nurse changed the patient's catheter with an 18 Fr, 30 ml Foley catheter. There was no evidence of an order for catheter type, size, maintenance, and change frequency.

Upon patient record review, 1 of 11 (Patient #8) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 8: The aide care plan update only included the task for assistance with ambulation. There was no evidence of the additional personal care tasks and precautions transferring to the updated aide care plan. Confirmed with leadership that the care plan should contain additional tasks.

Upon patient record review 4 of 11 (Patients #1,#3,#5,#8) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 1: The medical record contained an ordered aide frequency of eight times weekly. There was only evidence of two aide visits and one missed visit documented for the week of 12/25/22. Patient 3: The medical record contained an ordered aide frequency of once weekly. There was no evidence of aide visits made the week of 1/8/23. Patient 5: The medical record contained an ordered aide frequency of twice weekly. There was no evidence of aide visits made the week of 1/8/23. Patient 8: The medical record contained a recertification order with aide frequency effective 11/16/22 of four visits for one week, then six visits for eight weeks. There was evidence of two visits the week of 12/11/22, three visits the weeks of 12/18/22 and 1/1/23, and four visits the week of 12/25/22.

Upon patient client record review, 1 of 11 (Patient #5) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 5: The medical record contained an election of benefit form identifying patient request for Notice on Hospice Non-Covered Items upon admission 9/21/22. The form was documented as received 9/29/22, outside the 5 day timeframe.

Upon patient record review, 2 of 11 records (Patients #6,#7) did not have evidence that the hospice provided the following information: • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient Patient 6: Upon observation during home visit, there was no evidence of certification and recertification of the terminal illness or names and contact information for the hospice personnel involved in the hospice care. Patient 7: Upon observation during home visit, there was no evidence of certification and recertification of the terminal illness or names and contact information for the hospice personnel involved in the hospice care.

Upon personnel record review, 1 of 13 (Personnel #13) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions.

Upon personnel record review, 1 of 13 (Personnel #13) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel 13: The agency was unable to provide a personnel file to include a criminal background check for a speech language pathologist.

Upon personnel record review, 1 of 13 (Personnel #13) did not have evidence that all personnel have been fully vaccinated for COVID-19.