Every finding on record at Adobe Hospice of Florida LLC

Based on interview and record review, the hospice failed to appropriately track and analyze adverse patient events to enable to hospice to assess processes of care, hospice services, and operations. --- Findings include: During an interview on 11/12/2025 at 12:15 PM the Director of Quality stated that regarding falls with major injuries, she was not aware of them being a reportable event. There was not a process in place to review incident reports to identify areas of concern. During an interview on 11/12/2025 at 3:26 PM the Director of Quality stated, “We don’t currently have a process in place that would trigger a report to AHCA [the Agency for Health Care Administration]. I agree that we need a process in place. We currently don’t have a procedure in place to review a fall to see if an RCA [Root Cause Analysis] needs to occur.” Review of policy titled “Sentinel Events – Incident Reporting,” with the last review date of 3/25/2024 read, “I. Policy and Procedure Statement: [Name of the facility] requires that all incidents of a “sentinel nature” reported to the Compliance Officer and the Patient Care Manager of the patient care team involved by phone immediately upon learning the seriousness of the event, including after hours. The Compliance Officer will investigate all sentinel events. The event will also be reported via the Safety Zone Portal.  II. Definitions: A Sentinel Event is any unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof not related to the patient's illness or underlying condition. Major permanent loss of function is defined as sensory, motor, physiologic, or intellectual impairment not present on admission that requires continued treatment or lifestyle change. III. Procedure to Policy: C. Senior management will make the decision regarding whether or not the event fits the accrediting bodies definition of a Sentinel event and therefore is reportable to them. D. A root cause analysis will be coordinated by company on all events causing patient harm or having the potential to cause patient harm. The root cause analysis will be conducted by a member of the quality department as soon as possible, and findings will be reported to the quality council and the director of risk management as needed. E. Results of the analysis must be used to identify any changes that could be made in systems or processes to reduce the risk of a particular serious adverse event occurring in the future. F. The root cause analysis must be completed within 30 days of the sentinel occurrence. G. To prevent reoccurrence of the Sentinel event an action plan will be developed and implemented with oversight from the quality council. I. Management may require a root cause analysis of other incidents that although not covered by the definition of Sentinel, are of such a serious nature they demand such a review.”

Based on interview and record review, the facility failed to document in the medical record Patient #1’s treatment and services related to an unwitnessed event/fall. --- Findings include: Review of Patient #1’s admission data revealed the start of care was 6/12/2025. The hospice admitting diagnosis was Alzheimer’s disease. Review of Patient #1 Social Worker Note, dated 10/08/2025 read, “[Patient #1’s name] “with a hospice DX [diagnosis] of Alzheimer’s Disease. Patient is admitted to [name of the facility] for a 5-night respite stay. Patient will return home on Sunday October 12, 2025.” During an interview on 11/12/2025 at 1:01 PM the Director of Clinical Operations stated, “If a patient falls, I expect the nurse to do an initial assessment, notify the doctor, notify the family, find out the wishes of the family, and whether they want the patient sent to the hospital. I do expect the nurse to write a note about the falls. [Nurse A, RN’s name] called me the night [Patient #1’s name] fell. I reminded [Nurse A, RN’s name] to do the incident report, and I would have thought that one of the nurses would have written a nursing note. I did not know they did not put a note in until just now.” During an interview on 11/12/2025 at 3:09 PM Nurse B, RN (Registered Nurse) stated, “I did not document her fall, I believe [Nurse A, RN’s name] made a note because [Nurse A, RN’s name]  spoke with the nurse practitioner, the family and EMS (Emergency Medical Services). I was going off shift.” During an interview on 11/12/2025 at 3:51 PM Nurse A, RN stated, “The details were in the incident report, but not in the EMR (electronic medical record), because I didn’t do an assessment in the EMR.” During an interview on 11/12/2025 at 3:55 PM the Executive Director stated to Nurse A that he should have documented Patient #1’s fall, an assessment and intervention including notification to the ARNP (Advanced Registered Nurse Practitioner) and the daughter, and the information regarding Patient #1’s transfer to the hospital. The documentation in the medical record would be in addition to the incident report. Review of the policy and procedure titled “Fall and Injury Prevention,” with the last review date of 05/05/2023 read, “I. Policy and Procedure Statement: To promote patient safety and prevent injuries from falls.  II. A. Fall – An unintentional change in position resulting in coming to rest on the ground or at a lower level. III. Procedure to Policy: B. After a fall, the nursing staff will: 1. Assess patient’s condition and need for treatment. Seek appropriate treatment as needed for injuries or suspected injuries. 5. Document the fall in the EMR same day as incident”.  Review of the policy and procedure titled, “Patient Medical Record Documentation,” with the last review date of 8/05/2020 read, “I. Policy and Procedure Statement: In a clinical operation, it is critical to document each patient's condition and history of care. To ensure the patient receives the best available care, the information must be passed among all members of the interdisciplinary group of caregivers. Proper and timely same day documentation is always expected at [Name of Facility] for all interdisciplinary team of caregivers regardless of their exempt or non-exempt employment status. III. Procedure to Policy: A. Understand and guide staff's responsibility to provide and document patient history, condition, interventions, and education. The required essential components of the patient record includes, but is not limited to: . 6. symptom management, with response to interventions 7. Functional status, Completeness: D. ALL Documentation provided from admission, through each POS (point of service) and discharge must be included in the medical record. Timeliness: G. There are specific time requirements for completion of the medical record documentation related to patient condition, interventions, and education: all documentation must occur at POS. POS documentation is the process of documenting patient encounters as they occur, or immediately after. 2. Documentation at POS is the expected standard of practice at [Name of Facility]. Regardless of time of day, or employee status (exempt or non-exempt) all documentation is required to be entered into the patient's medical record as a patient is assessed or immediately after. Patient history at assessment or new relevant information arises, condition, interventions and responses to interventions, and education must be charted at the end of each shift to provide continuity of care from shift to shift in care center setting and by visit for home and facility team setting. It is the expectation that all staff document at POS and before their workday ends.”

Upon patient record review 1 of 7 (Patient #2) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Pt #2- Pt admitted 2/7/24. SC assessment completed 2/14/24.

Upon patient record review, 2 of 7 (Patient #3, 5) 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. Pt # 3 - No evidence of MRSA precautions and Hep C on nursing care plans . (Corrected on site) Pt #5 - Foley care not listed on care plan and no goals or interventions. (Corrected on site)

Upon patient record review, 1 of 7 (Patient #5) 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. Pt #5 - 2/13/24 order reads Foley catheter to be changed every 60 days and prn No size of catheter or prn reason on record. (Corrected on site)

Upon client record review, 3 of 7 (Patient #1, 5, 6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Pt #1 - No evidence of a volunteer order. Documentation in care plans states on 2/5/24 for volunteer services. Vol made a visit 2/24/24 - no order. (corrected on site) Pt #5 - Chaplain order of 2/12/24 states 1xday only. Chaplain saw patient 2/12 - chaplain documents family wants more visits and pt was seen again on 2/20/24. No order past the 1xvisit order (Corrected on site) Pt #6- Record reflects volunteer visit on 2/24/24. No order evident on medical IPU record (corrected on site)

Upon patient record review, 2 of 7 (Patient #3, 7) 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 Pt #3 - No mention of Hep C or MRSA precautions on aide POC. (Corrected on site) Pt #7 - Aide POC states patient is on a regular diet. Record review shows that patient has a feeding tube and is getting Jevity over 14 hours each evening along with food during the day as tolerated. (Corrected on site)

Upon patient record review 1 of 7 (Patient #2) 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 Pt #2 - Aide started 2/12/24 Missed visits documented for 2/13/24, 2/14/24, and 2/19/24. No further documentation in record. No order to stop care. (Corrected on site)

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 10 of 41 (Patient #2, #9,#10, #11,#15,#16,#17, #19, #26, #27) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #2: SOC 7/7/2023. Spiritual assessment on 7/13/2023. Patient #9: SOC 9/6/2023. Psychosocial assessment occurred on 9/19/2023 Patient #10: SOC 5/31/2023. Spiritual assessment occurred on 6/7/2023. Patient #11: SOC 11/9/2023. Spiritual assessment occurred on 11/20/2023. Patient #15: SOC 10/3/2023, Spiritual assessment occurred 10/31/2023. Patient #16: SOC 8/7/2023, Spiritual assessment occurred 8/14/2023. Patient #17: SOC 11/3/2023, Spiritual assessment and Psychosocial assessment occurred 11/9/2023. Patient #19: SOC 8/3/2023, Spiritual assessment occurred 8/11/2023. Patient #26: SOC 12/19/2022, Psychosocial assessment occurred 12/27/2022. Patient #27: SOC 3/9/2023, Spiritual assessment occurred 3/15/2023.

Upon patient record review 8 of 41 (Patient #14, #16, #23, #24, #25, #26, #38, #39) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #14: SOC 5/24/2023, there was no evidence of a Spiritual assessment. Patient #16: SOC 8/7/2023, there was no evidence of a Psychosocial assessment. Patient #23: SOC 9/23/2023, there was no evidence of a spiritual care assessment. Patient #24: SOC 1/4/2023, there was no evidence of a spiritual care assessment. Patient #25: SOC 3/29/2023, there was no evidence of a spiritual or psychosocial assessment. Patient #26: SOC 12/19/2022, there was no evidence of a spiritual assessment. Patient #38: SOC 2/22/22, there was no evidence of psychosocial assessment. Patient #39: SOC 8/11/23, there was no evidence of psychosocial assessment.

Upon patient record review, 22 of 41 (Patient #1, #2, #3,#4,#6,#7,#8,#10,#11,#12,#13,#14,#15,#16,#17,#21,#23, #27,#37,#38,#40,#41) 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: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: Medication profile dated 9/27/2023 included Diclofenac 1% tropical 2-3 GM PRN 3X day for pain, there was no evidence of an area to apply. Miralax 17GM oral powder 1 dose 1x day for constipation, there was no evidence of a diluent. Corrected on site. Patient #2: Medication profile dated 7/7/2023 included Miralax 17GM oral powder 1 dose 1x day for constipation, there was no evidence of a diluent. Corrected on site. Patient #3: Medication profile dated 12/18/2023 included O2 1-2L inhalation PRN SOB, there was no evidence of a route. Corrected on site. Patient #4: The medication profile includes Nystatin 100,00 unit/gram topical powder, it does not indicate an application site. (Medication profile corrected on site.) Patient #6: The patient record includes orders on 1/11/24 for oxygen PRN, this is not included in the medication profile. Patient #7: Medication profile dated 1/1/2023 included Miralax 17GM oral powder 1 dose 1x day for constipation, there was no evidence of a diluent. Corrected on site. Patient #8: Med. profile dated 4/25/2023 included O2 1-2L inhalation PRN SOB, there was no evidence of a route. Corrected on site. Patient #10: O2 dated 5/31/2023 2-4L PRN SOB, no evidence of a route. Corrected on site. Patient #11: Med. profile dated 11/9/2023 included O2 2-4L PRN SOB, no evidence of a route. Corrected on site. Patient #12: Med profile dated 11/4/2023 included O2 2-4L PRN SOB, no evidence of a route. IDG notes dated 11/16/2023 state Miralax added as an order due to constipation, No evidence of Miralax on Med. profile. Patient #13: Med. profile dated 10/12/2023 Monural oral packet 1 pkg Q 10 days for UTI , no evidence of a diluent. Corrected on site. Patient #14: Med. profile dated 5/24/2023 O2 Inhalation 2-4 LP PRN SOB, no evidence of a route. Corrected on site. Patient #15: Med. profile dated 10/12/2023 included O2 inhalation 2-4 PRN SOB, no evidence of a dose or route. Corrected on site. Patient #16: Med profile dated 8/7/2023 included O2 2-4 intranasal continuous, no evidence of a dose. Corrected on site. Patient #17: Med. profile dated 11/3/2023 included Polyethylene glycol 17GM oral powder 1 scoop 1x day, there was no evidence of a diluent. Corrected on site. Patient #21: POC included O2 concentrator under DME listed, SOC SN assess identified O2 need for SOB, there was no entry in the Med. profile for O2. Patient #23: Med. profile dated 9/30/2023 included O2 inhalation 2-4L PRN SOB, there was no evidence of a route. Patient #27: Med. profile dated 3/14/2023 included O2 inhalation 2-4L intranasal PRN, there was no evidence of an indication for use. Patient #37: The medication profile includes oxygen, it does not include a route of administration ie, nasal cannula, mask etc. Patient #38: The orders upon admit to Respite care includes orders for oxygen 2-4LPM via nasal canula PRN, the order is not included in the medication profile. Patient #40: The patient record includes orders on 1/5/24 for oxygen PRN, this is not included in the medication profile. Patient #41: The medication profile includes polyethylene glycol 3350 17gram powder 1 prn for constipation, it does not include instructions for dilution.

Upon patient record review, 13 of 41 (Patient #4,#9,#10,#16,#17,#19,#25,#26,#32,#36,#38,#39,#40) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #4: The patient was admitted on 11/29/23, the bereavement risk assessment has not been completed. Patient #9: SOC 9/6/2023. Bereavement assessment occurred on 9/19/2023. Patient #10: SOC 5/31/2023. Bereavement assessment occurred on 6/7/2023. Patient #16: SOC 8/7/2023. There was no evidence of a Bereavement assessment. Patient #17: SOC 11/3/2023. Bereavement assessment occurred on 11/9/2023. Patient #19: SOC 8/3/2023. Bereavement assessment occurred on 8/11/2023. Patient #25: SOC 1/4/2023. There was no evidence of a bereavement assessment. Patient #26: SOC 12/19/2023. Bereavement assessment occurred on 12/27/2023. Patient #32: SOC 10/21/23, the bereavement risk assessment was not completed. Patient #36: SOC 1/4/24, the bereavement risk assessment was not completed. Patient #38: SOC 2/22/23, the bereavement risk assessment was not been completed. Patient #39: SOC 8/11/23, the bereavement risk assessment was not been completed. Patient #40: SOC 1/5/24, the bereavement risk assessment was not completed.

Upon patient record review, 1 of 41 (Patient #19) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #19: Comprehensive RN assessment dated 8/31/2022 next visit/assessment 9/16/2022 greater than 15 days.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 1 of 41 (Patient #36) 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 #36: The narrative note included on the RN assessment on 1/6/24 indicates that the patient has a “DTI to the left heel, an open stage II wound to the rectum, and 2nd toe to left foot is black.” There is no evidence in the record that this was reported to the MD/NP and a complete wound care assessment was not completed for the GIP admission.

Upon patient record review, 10 of 41 (Patient #6,#17,#20,#23,#28,#32,#36,#37,#38,#39) 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 #6: The patient was admitted on 6/3/23 and the patient record indicates that the patient uses diabetic medications and insulin that includes Lantus 14 units at bedtime, Tradjenta 5mg daily, and Humalog 4 units before meal and performs acu-checks 3 times a day. The initial plan of care does not include a problem statement with interventions and goals for the management and assessment of the diabetes. The bereavement risk assessment indicated a “moderate” risk for grief/bereavement, the plan of care does not include interventions and goals to address the caregiver needs. Patient #17: SOC SN assess identified pt. has trach tube, CPAP, and a g-tube. The POC had no evidence of problems/interventions goals for C/R including trach and CPAP, and Peg tube care. Corrected on site. Patient #20: CTI at SOC identifies Aspiration risk, no evidence on POC of aspiration precautions. corrected on site. Patient #23: SN SOC assess identifies colostomy and JP drain, there was no evidence on the POC for problem/interventions/goals for colostomy or JP drain. Patient #28: The patient was admitted on 12/7/23 and receives Eliquis 5mg BID, the plan of care does not include bleeding precautions. Patient #32: The patient was admitted on 10/21/23, the initial comprehensive assessment performed by the RN indicated “wife is very tearful” and documented patients daughter died of cancer, son has been diagnosed with leukemia and PCG is currently being tested for breast cancer, patient and PCG are taking care of 13 year old granddaughter. The plan of care does not include a problem statement with interventions and goals for the current and anticipated grief of the PCG. Patient #36: The patient was admitted on 1/4/24 and had a foley catheter placed due to urinary retention within the first 24 hours of her GIP admission, the plan of care does not include a problem statement for the urinary retention or for the use of the foley catheter with interventions and goals. Patient #37: The patient was admitted on 1/10/24, the initial comprehensive RN assessment includes documentation of a stage II pressure ulcer to the sacrum/coccyx and an unstageable wound to the right heel with eschar. The plan of care does not include a problem statement with interventions and goals for the wound management. Patient #38: The patient was admitted on 2/22/23, the plan of care was not completed until 3/1/23 with problems, goals and interventions. Patient #39: The patient was admitted on 8/11/23 with a secondary condition of COPD and requires continuous use of oxygen, the plan of care does not include a problem statement with interventions and goals for respiratory.

Upon patient record review, 3 of 41 (Patient #12,#24,#27) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #12: Order dated 11/4/2023 included SN PRN visits x 15 between 11/4-2/1/2024. Patient #24: Order dated 1/4/2023 SN visits 1x week and 10 PRN. Patient #27: Order dated 3/9/2023 SN visits 1x week and 19 PRN 3/9-3/25/2023.

Upon patient record review, 22 of 41 (Patient #1,#2#3,#4,#6,#7,#8,#10,#11,#12,#13,#14,#15,#17,#21,#23, #27,#37,#38,#39,#40,#41) 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 #1:Order dated 9/27/2023 included Diclofenac 1% tropical 2-3 GM PRN 3X day for pain, there was no evidence of an area to apply. Order dated 9/27/2023 included Miralax 17GM oral powder 1 dose 1x day for constipation, there was no evidence of a diluent. Corrected on site. Patient #2: Order dated 7/7/2023 included Miralax 17GM oral powder 1 dose 1x day for constipation, there was no evidence of a diluent. Corrected on site. Patient #3: Wound orders dated 12/18/2023 included wound cleanser, apply Opti foam, change Q 5-7 days PRN, start 12/19/2023. There was no evidence of where the wound care was to be applied and who was to do it. Order dated 12/18/2023 included O2 1-2L inhalation PRN SOB, there was no evidence of a route. Corrected on site. Patient #4: The medication orders for Nystatin powder 100,000 unit/gram topical powder, does not include an application site. The patient record indicates that the patient has a foley catheter, the date of placement is not identified in the record, the plan of care does not include orders for placement of the foley catheter. (Order corrected on site) Patient #6: The order for oxygen prn on 1/11/24, does not include an indication for use. Patient #7: Order dated 1/1/2023 included Miralax 17GM oral powder 1 dose 1x day for constipation, there was no evidence of a diluent. Corrected on site. Patient #8: Order dated 4/25/2023 included O2 1-2L inhalation PRN SOB, there was no evidence of a route. Patient #10: O2 dated 5/31/2023 2-4L PRN SOB, no evidence of a route. Corrected on site. Patient #11: Order dated 11/9/2023 included O2 2-4L PRN SOB, no evidence of a route. Corrected on site. Patient #12: Order dated 11/4/2023 included O2 2-4L PRN SOB, no evidence of a route. IDG notes dated 11/16/2024 state Miralax added as an order due to constipation, No evidence of an order. Patient #13: Order dated 10/12/2023 Monural oral packet i pkg Q 10 days for UTI , no evidence of a diluent. Corrected on site. Patient #14: Order dated 5/24/2023 O2 Inhalation 2-4 LP PRN SOB, no evidence of a route. Corrected on site. Patient #15: Order dated 10/12/2023 included O2 inhalation 2-4 PRN SOB, no evidence of a dose or route. corrected on site. Patient #17: Order dated 11/3/2023 included Polyethylene glycol 17GM oral powder 1 scoop 1x day, there was no evidence of a diluent. Corrected on site. Patient #21: POC included O2 concentrator under DME listed, SOC SN assess identified O2 need for SOB, there was no order for O2. Patient #23: Order dated 9/30/2023 included O2 inhalation 2-4L PRN SOB, there was no evidence of a route. Patient #27: Order dated 3/14/2023 included O2 inhalation 2-4L intranasal PRN, there was no evidence of an indication for use. Patient #37: The patient record includes an order on 1/9/24 for foley catheter, PRN, there is no indicator for use. (Corrected on site.) Patient #38: The order for oxygen prn on 1/8/24, does not include an indication for use. Patient #39: The order for oxygen prn on 11/24/23, does not include an indication for use. Patient #40: The order for oxygen prn on 1/5/24, does not include an indication for use. Patient #41: The order for oxygen prn on 1/7/24, does not include an indication for use.

Upon client record review, 1 of 41 (Patient #19) 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 #19: IDG update occurred on 9/15/2022 and again until 10/13/2022, greater than 15 days.

Upon patient record review, 7 of 41 (Patient #6,#15,#28,#29,#36,#38,#39) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #6: The patient was admitted on 6/3/23, there is no evidence in the patient record that the plan of care has been updated since 6/6/23. Patient #15: Eliquis added to med profile, orders 10/26/2023, no evidence on updated POC of bleeding precautions. Corrected on site. Patient #28: The patient record indicates that the patient receives MSW visits, the plan of care does not include a problem statement with interventions and goals for the services. The plan of care is not updated to include caregiver needs, interventions and goals for respite services. Patient #29: The patient was placed into respite care on 1/5/24 and received a foley catheter on that date, the plan of care was not updated to include the problem, interventions or goals for genitourinary needs. Patient #36: The patient received new orders on 1/5/24 to infuse bolus feedings using the g-tube that is in place. The plan of care was not updated to include the nutrition and use of the g-tube with interventions and goals for care. Patient #38: The patient was admitted to respite care from home on 1/8/23, the patient record does not include documentation of the respite needs, coordination of care or the goals for the level of care changes. The patient record does not include a plan of care update for the benefit period starting 10/20/23. Patient #39: The patient record does not include a plan of care update for the benefit period starting 11/9/23.

Upon client record review, 16 of 41 (Patient #2,#4,#6,#7,#8,#14,#16,#19,#21,#29,#31,#33,#34,#37,#39,#40) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: Order dated 7/10/2023 included Spiritual Care visits 1x month. there was no evidence of a SC visit in the month of November 2023. Patient #4: The patient received visits from the social worker on 12/1/23, 12/19/23, 12/28/23 and 1/8/24, the plan of care does not include orders for SW visits. The patient received visits on 12/29/23 and 1/5/24 from spiritual care services, the plan of care does not include orders for spiritual care services. Patient #6: The patient record includes evidence of volunteer services and visits being received, there are no frequency orders in the plan of care for volunteers. The visit frequency for nursing starting 6/3/23 is ordered for 1 time per week for 14 weeks. The patient did not receive a visit for the week of July 2 -8, 2023 Patient #7: Volunteers making visits with no Plan of care for volunteers or visit frequencies ordered. VC POC for volunteers is blank. Corrected on site. Patient #8: Volunteers making visits with no Plan of care for volunteers or visit frequencies ordered. VC POC for volunteers is blank. Corrected on site. Patient #14: SN visits ordered 11/20/2023 SN 1x week x 9. Week of 11/26/2023 no evidence of a visit or missed visit. Patient #16: Order dated 9/18/2023 SW visits 1x month x 2. No evidence of SW visits or missed visits for September or October 2023. Patient #19: Volunteers making visits with no POC or orders for visit frequencies. VC POC for volunteers is blank. Corrected on site. Patient #21: Volunteers making visits with no Plan of care for volunteers or visit frequencies ordered. VC POC for volunteers is blank. Patient #29: The orders for nursing visits starting 12/16/23 are for 2 times per week. The patient received 1 visit the week of 12/24/23 and no visits the week of 12/31/23. Patient #31: The patient record includes documentation on 12/19/23 of bilateral stage III wounds to buttocks and wound care being provided. The plan of care does not include wound care orders. (Corrected on site.) Patient #33: The patient record includes evidence of a stage II pressure ulcer to the coccyx, wound care was performed on 1/7/24 without orders. Patient #34: The patient record indicates the patient received volunteer services and 6 visits from 9/5/23 – 9/29/23, the plan of care does not include frequency orders for volunteer services. The patient received SW calls and services on 10/3/23, 11/15/23, 1/6/24 and 1/8/24 with no frequency orders since 7/30/23. Patient #37: The patient record upon admit includes evidence of a stage II wound to the sacrum/coccyx and an unstageable wound to the patients right heel. The RN assessment on 1/11/23 does not include documentation of the wounds and the plan of care does not include care orders for the right heel wound although wound care was provided. Patient #39: The patient received SW visits on 1/11/24, 1/5/24, 12/28/23, 12/22/23, 12/21/23, 12/14/23, 12/7/23, 12/1/23, 11/30/23, 11/28/23 and 11/27/23 with no visit orders included in the plan of care. The patient received spiritual care visits on 1/9/24 and 11/29/23 with no orders included in the plan of care. The patient began receiving volunteer services effective 11/25/23, there are no frequency orders for volunteer records included in the plan of care. Patient #40: The patient received SW visits on 1/12/24 & 1/11/24 with no frequency orders included in the plan of care.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon patient record review, 19 of 41 (Patient #4, #5, #6, #10, #18, #19, #20, #21, #22, #25, #27, #28, #29, #30, #31, #36, #37, #38, #39) 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 #4: The hospice aide task assignment does not specify frequency for performing bathing, shampoo, oral care, linen changes. (Corrected on site.) Patient #5: The hospice aide task assignment does not specify the frequency for performing linen changes and catheter care. (Corrected on site.) Patient #6: The hospice aide task for shower does not include a frequency. Patient #10: SOC SN assess identifies Seizure disorder, diagnosis of Intra cranial injury, on seizure medications. Aide assignment does not include seizure precautions. Corrected on site. Patient #18: SOC SN assess identifies dysphagia, aspiration risk. There was no evidence on the Aide assignment for swallowing precautions. Corrected on site. Patient #19: Order dated 11/26/2023 Aide visits PRN x 3 from 11/26-1/24/2024. Patient #20: SOC SN assess identifies swallowing difficulties, no evidence of swallowing precautions, no evidence of frequencies for personal care tasks on aide assignment. Corrected on site. Patient #21: Pt on O2, prescribed Eliquis, no evidence on aide assignment of bleeding or O2 precautions. Patient #22: Pt on Eliquis, no evidence on Aide assignment for bleeding precautions. Patient #25: Order for aide visits 4/3/2023, visits done, no evidence of an Aide assignment/POC. Patient #27: SN SOC assess identifies O2, fall risk, and risk for aspiration, no evidence on aide assignment of O2, fall or swallowing precautions. Order dated 3/9/23 Aide visits 25 PRN 3/9-3/25/2023. Patient #28: The hospice aide task for bath, shaving, shampoo, apply lotion, nail care and linen change does not include a frequency. (Corrected on site.) Patient #29: Hospice frequency orders entered on 12/16/23 include PRN visits x 3. Hospice aide task assignments starting on 1/5/24 for shampoo, hair care and nail care do not include a frequency. (Corrected on site.) Patient #30: The hospice aide task assignments for hair care and shampoo do not include a frequency, the frequency for changing linens is written “as desired.” Patient #31: The hospice aide task assignments for bath, nail care, hair care and linen changes do not include a frequency. Patient #36: The hospice aide tasks for bed bath, shampoo, comb hair, nail care, skin care and linen changes are not assigned a frequency. Patient #37: The task assignment for linen change is indicated as “when soiled” and is not assigned a specific task frequency. Patient #38: The patient is receiving respite care and has aide tasks assignment of a bedbath, the patient is ambulatory and independent of toileting. The hospice aide tasks for bedbath, shampoo, combing hair, nail care, skin care and linen changes are not assigned a task frequency. Patient #39: The hospice aide tasks for shower, bath, linen change, nail care, shampoo hair, comb hair, skin care with lotion and oral hygiene do not include a frequency.

Upon patient record review 11 of 41 (Patient #1,#3,#7,#9,#13,#20,#32,#36,#37,#40,#41) 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: Order dated 10/4/2023 for Aide visits 1x week for 13 weeks. Soc. 9/27/2023, no visit or missed visit for week one (9/17/2023) or week 2 - 10/1/2023, first Aide visit occurred on 10/18/2023. Patient #3: Order 12/24/2023 Aide visits 2x12, week of 12/24/2023 one visit occurred on 12/26/2023 with no evidence of a missed visit. Patient #7: Order dated 10/30/2023 for Aide visits 3x week. For week 11/19/2023 and week 12/31/2023, 2 Aide visits occurred with no missed visits. Patient #9: Order 12/10/2023 Aide visits 3x week, week of 12/24, 12/31/2023 each with 2 visits. Patient #13: Order 10/20/23 Aide visits 3x week, weeks 11/19, 11/26, 12/17,12/24 and 12/31 each with 2 visits per week. Patient #20: Order 10/17/2023 Aide visits 2x week, week of 12/31/2023 one visit completed, with no missed visits. Patient #32: The hospice aide orders starting on 11/26/23 to 12/29/23 were indicated for 3 times per week. The record includes 12 missed visits during that time period. Patient #36: The patient was admitted on 1/4/24 to general in-patient care and has hospice tasks assigned daily, there is no evidence in the record of tasks being performed for care. Patient #37: The patient was admitted on 1/10/24 to general in-patient care and has hospice tasks assigned daily, there is no evidence in the patient record of tasks being performed for care. Patient #40: The patient is admitted to GIP care effective 1/5/24, aide tasks assigned daily, there is no evidence in the patient record of hospice aide cares being provided until 1/10/24. Patient #41: The patient was admitted to GIP services effective 1/7/24 with hospice aide services to be provided daily, there is no evidence in the patient record of a hospice aide cares being provided.

Upon patient client record review, 1 of 41 (Patient #9) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #9: 85 year old male with diagnosis of Parkinson's disease as primary. IDG notes for 9/28/2023 included summary "67 year old male with malignant neoplasm of prostate". No evidence of appropriate authentication. Corrected on site with addendum.

Upon client record review, 2 of 41 (Patient #21, #22) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patients #21, #22: No evidence a discharge summary was sent to the patients attending physician.

Upon client record review, 2 of 41 (Patient #21, #22) did not have evidence that the discharge summary includes all required information. Patients #21, #22: there was no evidence the discharge summary included a summary of the pts stay, current plan of care or latest physicians orders.

Upon patient record review, 1 of 41 (Patient #33) did not have evidence in the patient record that patients receiving care in a hospice that provides inpatient care directly in its own facility have medications administered by only one of the following individuals: • A licensed nurse, physician, or other health care professional in accordance with their scope of practice and state law • Personnel who have completed a state-approved training program in medication administration • The patient, upon approval by the interdisciplinary group Patient #33: The patient was admitted to general inpatient care within an agency owned facility. Documentation on 1/5/24 by the RN indicates that a family member administered dexamethasone 4mg and miralax to the patient without approval or consent from the IDG. The dexamethasone was not included in the plan of care and the agency policy is that patients/families are not allowed to bring in medications or self administer medications.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family.

Upon client record review, 41 of 41 (Patient #1, #2, #3, #4, #5, #6, #7. #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed.

Upon patient record review, 2 of 41 (Patient #7, #8) did not have evidence that the hospice provided the following information to the SNF: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient • 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 • Instructions on how to access the hospice's 24-hour on-call system • Hospice medication information specific to each patient • Hospice physician and attending physician (if any) orders specific to each patient Patient #7: There was no evidence of a Hospice election form, consents for care, and name and contact info for hospice personnel. Corrected on site. Patient #8: There was no evidence of a Hospice election form, consents for care, Physician certification of terminal illness, and name and contact info for hospice personnel. Corrected on site.

Upon personnel record review, 1 of 16 (Personnel #15) 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. Personnel #15: there was no SLP record provided.

Upon personnel record review, 1 of 16 (Personnel #15) 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.

Upon observation, there was no evidence the fire alarm systems of a facility are provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. Existing Construction During the document review, the facility fire alarm testing report dated 11/16/2023 showed three (3) devices failed. At the time of survey, the facility has not corrected the failed devices per NFPA 72-2010, or completed an Alternative Life Safety Measures assessment to compensate for the failed devices per NFPA 101-2012. The agency did not have a fire watch plan in place. During the inspection, it was observed that an enclosed and screened patio contained two ashtrays with multiple cigarette butts in each in an area that is clearly marked as a NO SMOKING area. The facility and its entire property is designated as a non-smoking facility.