Every finding on record at Adonis Hospice, Inc.

Upon patient record review, 8 of 14 (Patient #1,3,4,5,6,7,8,9) 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 #1,No evidence of funeral home documented on MSW initial assessment. No evidence of care plan to address plan for funeral home arrangements. Patient #3, Patient has terminal diagnosis of Cardiac disease. No evidence of Cardiac care plan. No evidence of MSW care plan addressing patient full code status. Patient #4,5,6,7, No evidence of MSW care plan addressing patient full code status. Patient #8, Patient has terminal diagnosis of Rheumatoid Arthritis. No evidence of Rheumatoid Arthritis care plan. Patient #9, No evidence of plan of care.

Upon patient record review, 1 of 14 (Patient #4) 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, Basaglar kwik pen 100 units/ml, order read inject 37 ml every night. Admelog Solostar 100units/ml, order read inject 7 ml 3x/day before meals. These are incorrect as should be units vs mL. COS.

Upon client record review, 1 of 14 (Patient #3) 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 #3, No MD signature on IDG note dated 6/2/25 and 6/13/25 to show collaboration for review and revision of POC.

Upon client record review, 1 of 14 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1, LVN note on 6/6/25 documents wound care being performed per standard clinical guidelines. No evidence of wound care orders noted.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1, LVN place bag on the table without placing barrier between the bag. Patient #2, LVN place bag on the table first then placed barrier under the bag after bag had already been placed on the table without a barrier.

Upon personnel record review, 1 of 13 (Personnel #5) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #5, No evidence of rectal thermometer, ace bandage or ambulation with cane was observed. Documented as verbal.

Upon patient record review 2 of 14 (Patient #1,5) 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, Aide care plan directs aide to apply lotion. On 6/16/25, no evidence this was completed as the box was left empty. Patient #5, Physician order frequency was 2x/week. No evidence of visits completed 2x/week, visits completed 1x/week on 6/6, 6/13/25.

Upon patient record review 2 of 14 (Patient #3,7) 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 #3, Aide visits x3 weeks with no evidence of supervisory visit completed. Patient #7, Aide visits started on 5/1/25, with no evidence of supervisory visit completed until 5/20/25.

Upon patient record review, 13 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,14) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #1,2,3,4,5,6,7,8,9,10,11,12,14, No evidence of clinical documentation on physician narrative.

Upon patient client record review, 1 of 14 (Patient #1) did not have evidence that each patient record contains Advance Directives. Patient #1, Consent documents patient has a living will. No evidence of copy of living will in file.

Upon patient client record review, 1 of 14 (Patient #1) 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 #1, Consents state patient has a living will. MSW initial visit documents N/A. Emergency level documents level 3 on Plan of Care which means no need for help. Consents state patient emergency level is Red, requiring total assistance. No evidence of consistency on emergency levels.

Upon client record review, 2 of 14 (Patient #11,12) did not have evidence that the discharge summary includes all required information. Patient #11, 12, No evidence the discharge summary included the plan of care and goals that were met or not met.