Every finding on record at Accord Palliative and Hospice Care, Inc

Upon patient record review, 7 of 14 (Patient #1,#2,#4,#5,#6,#12,#13) 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. This review includes, but is not limited to: • Actual or potential drug interactions • Drug therapy currently associated with laboratory monitoring Patient #1: Oxygen at 2L per NC was present on the initial plan of care, but not listed on the medication profile. Additionally, MiraLAX was listed on the medication profile, but without a diluent. Patient #2: Per the CTI signed by the MD on 4/18/25 and the RN assessment dated 04/04/25, the patient was using oxygen @2-4 L Per NC, but oxygen was not listed on the medication profile. Patient #4: Tramadol Q8 hours PRN and Zofran Q6 hours PRN were listed on the medication profile with no evidence of a reason. Additionally, Nitroglycerine was on the medication profile, but there was no evidence of instructions for use. Patient #5: MiraLAX was on the medication profile, but there was no evidence of a diluent. Patient #6: Senna S was on the medication profile as daily PRN, but there was no evidence of a reason. Patient #12: Per the recert CTI, the MD indicated the patient was using intermittent O2, and 30 mg of Trazadone, but oxygen and Trazadone were not listed on the medication profile. Patient #13: The SN indicated the patient was using O2 @ 2L on the initial POC and the assessment dated 03/16/25, however, oxygen was not listed on the medication profile.

Upon patient record review, 2 of 14 (Patient #1,13) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #1: The plan of care completed 12/31/25 indicated the facility was to provide wound care, but the hospice SN was to assess and measure the wounds weekly. However, on the weeks of beginning 01/04/26 and 01/11/26, the SN did not assess or measure the wounds, but instead wrote, "wound care per facility." Patient #13: The comprehensive assessment dated 03/16/25 indicated the patient had a Stage 2 pressure ulcer, but the wound assessment was incomplete without evidence of assessment of the wound bed, exudate, and odor.

Upon patient record review, 5 of 14 (Patient #2,#4,#6,#11,#12) 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 patient was diagnosed terminally ill with Cerebral Infarct, but there was no evidence of a Neuro care plan. Patient #4: The patient was diagnosed terminally ill with Senile Degeneration, but there was no evidence of a Neuro care plan. Patient #6 #11: The patient was diagnosed terminally ill with Alzheimer's, but there was no evidence of a Neuro care plan. Patient #12: The patient was terminally ill diagnosed with Dementia, but there was no evidence of a Neuro care plan.

Upon patient record review, 2 of 14 (Patient #4,#6) 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 #4: Tramadol Q8 hours PRN and Zofran Q6 hours PRN were listed on the plan of care with no evidence of a reason. Additionally, Nitroglycerine was on the plan of care, but there was no evidence of instructions for use. Patient #6: Senna S was on the plan of care as daily PRN, but there was no evidence of a reason.

Upon client record review, 4 of 14 (Patient #5,#9,#10,13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #5: IDG care plans dated 02/11/26 and 02/25/26 indicated the SN frequency was 1x week. However, during the week of 02/08/26 the SN visited 2x on 02/08 and 02/14 then during the week of 02/22/26 and 02/28/26 there was no evidence of an SN visit. Patient #9: Care plans dated 1/29/26, 2/11/26 and 2/25/26 indicated the SN frequency was 1x week, but the SN visited the patient 2x week during the weeks beginning 2/9/26, 2/18/26 and 2/25/26. Patient #10: An order written on 2/22/26 clarified SN frequencies were 2x week through 2/21/26. However, during the week of 2/15/26 to 2/21/26 the SN visited 3x on 2/15, 2/18, and 2/21. Additionally, the IDG care plan dated 02/11/26 indicated SN visits were 1x week. Patient #13: The comprehensive assessment dated 03/16/25 indicated the patient had a Stage 2 pressure ulcer, without supporting evidence the dressing was done and wound orders were completed.

Upon patient record review, 4 of 14 (Patient #2,#6,#12,#13) 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 #2:The patient's medication profile listed ASA, but there was no evidence that bleeding precautions were part of the aide care plan dated 04/15/25. Additionally, the SN assigned "shower/bed bath as patient will allow" which is not specific. Patient #6:ASA was listed on the patient's medication profile, but there was no evidence of bleeding precautions on the aide care plan dated 06/03/25. Patient #12:ASA was listed on the medication profile, but there was no evidence bleeding precautions were part of the aide care plan. Additionally, the aide care plan created from a previous admission and dated 04/30/22, was no longer an active care plan for this patient. Patient #13:Eliquis was listed on the patient's medication profile, but there was no evidence that bleeding precautions were part of the aide care plan. Additionally, the aide care plan written on 03/16/25 indicated the patient had an open wound and aide was to apply barrier cream. However, the wound was healed on 04/10/25 according to the SN, but there was no evidence the aide care plan was updated.

Upon patient record review 2 of 14 (Patient #4,#14) 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 #4: The IDG care plans dated 01/29/26, 02/11/26 and 02/25/26 indicated hospice aide visits were ordered 3x week, however, during the month of February 2026, the aide visited the patient 5x per week. Patient #14: During the month of August, the aide visited the patient 5x per week, but the IDG care plans dated 07/30/25, 08/13/25 and 08/27/25 indicated the aide frequency was 2x week.

Upon patient client record review, 1 of 14 (Patient #10) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #10: The notification of non-covered services form was signed on 04/27/25 and had a checked box indicating the patient had requested the notification addendum, but there was no date inserted. Additionally, there was no notification of non-covered services provided 5 days from 04/27/25.

Upon client record review, 2 of 14 (Patient #4,#14) 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. Patient #4: SN frequencies were ordered as 1x week on 02/15/26, however, during the week of 02/15/26-02/21/26, the SN visited twice/week on 02/15/26 and 02/21/26. Additionally, during the week of 02/22/26-02/28/26 the SN visited twice/week on 02/23/26 and 02/25/26. Patient #14: IDG Care plans dated 07/30/25, 08/13/25 and 08/27/25 indicated SW visits were 1x week. However, there were no SW visits for the weeks of 08/03-08/09/25 and 08/17-08/23/25.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed it was revealed that the agency did not ensure that the patient’s individualized written plan of care identified planned interventions based on problems identified in the initial comprehensive assessment. Clinical Record 2: The patient elected the hospice benefit on 4/4/2023. The initial comprehensive assessment completed by the registered nurse on 4/4/23 documented “Patient now has pain due to kidney infection, eye infection and pneumonia”. The plan of care (POC) dated 4/4/23 to 6/2/23, did not include the patient's pain as a problem and did not include interventions to manage pain and symptoms. Clinical Record 5: The patient elected the hospice benefit on 4/21/23. The Registered Nurse (RN) conducted an initial comprehensive assessment dated 4/21/23 and documented, “Patient has problems with nausea and spitting out bile”. The plan of care (POC) dated 4/21/23 to 7/19/23, did not include the patient's nausea as a problem and did not include interventions to manage nausea. In a joint clinical record review and interview conducted on 5/10/23 the Director of Clinical Services (DCS) validated the findings.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as, hand hygiene. This standard was not met as evidenced by document review, interview and observation. In 2 of 3 (67%) home visit observations, it was revealed that the agency did not ensure that the staff member used standard precautions such as hand hygiene that followed accepted standards of practice and agency policy. Document 1: The agency policy titled; Hand Hygiene Policy (rev. 8/15/22), stated in relevant parts, "D. Staff may use an alcohol-based hand rub for routinely decontaminating hands in the clinical situations described below: 8. after removing gloves". Home Visit 1: During the home visit on 5/10/23 with a hospice aide (Staff 1), the staff was observed doffing their gloves after performing personal care of the patient and donning new gloves without first performing hand hygiene as defined in agency policy. Home Visit 2: During the home visit on 5/10/23 with a Registered Nurse (RN), Staff 5 was observed doffing their gloves after performing a hands-on assessment of the patient and donning new gloves without first performing hand hygiene, as defined in agency policy. In an interview conducted on 5/10/23, the Director of Clinical Services (DCS) confirmed that during home visits 1 and 2 the agency staff did not follow standard precautions and established agency policy IC.15 for hand hygiene.