Every finding on record at Adoration Hospice L L C

Based on policy review, medical record review, observation and interview, the facility failed to ensure the resident's drug profile was accurate for 2 of 4 (Patient #1 and 2) patients with home visits. --- The findings included:1.Review of the facility's, "Medication Profile" policy, revised October 2019 revealed, "PURPOSE To define the use of the medication profile in evaluating a patient’s medication regimen. POLICY Patients receiving medication administered by the organization will have a current, accurate medication profile in the clinical record. The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications…PROCEDURE…3. A drug regimen review will be performed at the time of initial and comprehensive assessment, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold and with the addition of a new medication…4. During subsequent home visits, the medication profile will be used as a care planning and teaching guide…” 2. Medical record review revealed Patient #1 was admitted on 8/1/2025 with a primary diagnosis of Chronic Obstructive Pulmonary Disease.  Review of the Client Medication Report revealed the following medications: Docusate sodium (a medication to treat constipation) 100 milligrams (mg) daily by mouth, Ibuprofen (a medication for pain) 800 mg one tablet every 8 hours by mouth, as needed (PRN), and prednisone (a medication to treat inflammation) 20 mg tablets 2 times per day by mouth. Observations during the home visit on 8/4/2025 at 2:20 PM, revealed there was no Docusate sodium or Ibuprofen in Resident #1's medications. There was a bottle of Prednisone 10 mg tablets (instead of Prednisone 20 mg tablets as listed on the Client Medication Report). In an interview on 8/4/2025 at 2:25 PM, Registered Nurse (RN) #1 verified the Client Medication Report was not accurate. 3. Medical record review revealed Patient #2 was admitted on 6/22/2022 with a primary diagnosis of Dementia.  The Client Medication Report revealed the following medications: Claritin (an allergy medication) 10 mg tablet daily, Robitussin (medication to relieve cough and congestion) extended release 30 mg/5 milliliter (mL) oral suspension 10 mL 2 times per day PRN. Observations during the home visit on 8/5/2025 at 9:00 AM, revealed there was no Claritin or Robitussin in Resident #2's medications. In an interview on 8/5/2025 at 9:10 AM, the caregiver stated the patient was no longer taking Claritin or Robitussin. 4. In an interview on 8/6/2025 at 10:50 AM, the Director of Clinical Practice verified the clinical staff should ask the patient if they have had any medication changes at each home visit and update the medication list accordingly.

Based on policy review, document review and interview, the facility failed to ensure the Volunteer cost savings achieved at least 5% annually for 1 of 1 calendar year (2024/2025) reviewed. --- The findings included:1.  Review of the facility policy “Volunteer Services” revised October 2019 revealed, “…POLICY The hospice will provide volunteer services under direction of a Volunteer Coordinator and with the assistance of trained hospice volunteers…PROCEDURE Th Volunteer Coordinator will develop, implement and evaluate the volunteer services program on an ongoing basis but at least annually….The Volunteer Coordinator will track the use of volunteers, the cost savings achieved, and that the hours of volunteer services will exceed 5% of the total patient care hours of paid and contracted hospice personnel. 2. Review of the facility’s Hospice Volunteer Service Report from January 2024 through December 2024 revealed a total cost savings of 1.35%.  Review of the facility’s Hospice Volunteer Service Report from August 2024 through August 2025 revealed a total cost savings of 1.63%. 3. In an interview on 8/5/2025 at 1:10 PM, Volunteer Coordinator #1 stated she was aware the cost savings did not meet the 5% requirement. In an interview on 8/5/2025 at 1:15 PM, the Director of Clinical Practice verified the Hospice Volunteer Service Reports were correct, and the facility did not meet the 5% cost savings goal.

Based on agency policy review, medical record review, Assisted Living Facility (ALF) record review, and interview the agency failed to update the medication profile for 1 patient (#1) of 3 patients reviewed with home visits. The findings include: Review of the agency's policy titled, "Medication Profile," revised 5/11/2020, showed "...A drug regimen review will be performed...with the addition of a new medication...using the medication profile as a communication tool for other clinicians involved in care..." Patient #1 was admitted to the agency on 11/18/2021 with diagnoses including Alzheimer's Disease, Urinary Tract Infection, and Adult Failure to Thrive. Review of Patient #1's Medicine List showed medication orders for "...Atropine 1% Eye Drops-Ophthalmic (Eye) [medication used to treat terminal secretions]...2 drops sublingual every 15 minutes...Guaifenesin 100mg/5ml [milligram/milliliters]...[cough medication used to treat overproduction of sputum]...2 times daily..." Review of Patient #1's ALF Order Summary Report dated 6/21/2022, showed no documentation the patient had orders to receive the Atropine or the Guaifenesin medications. During an interview on 6/22/2022 at 8:55 AM, the Administrator confirmed Patient #1's medication profile had not been reconciled with the ALF, to ensure medication list included the addition of a new medication. She further confirmed the medications should be reconciled on each skilled nurse visit.

Based on review of agencies policy, medical record review, and interview, the agency failed to notify the physician of a change in condition for two patients (#3 and #4) of 13 patients reviewed. The findings include: Review of the facility's policy titled, "Monitoring Patient's Response/Reporting to Physician," revised 5/11/2020, showed "...PURPOSE...To provide...monitoring...and for reporting to the patient's physician...The patient's physician...or the Medical Director will be contacted the same day when...Changes in the patient's condition...There is any problem implementing the plan of care..." Patient #3 was admitted to the agency on 1/12/2022 with diagnoses to include Cerebral Ischemia, Dementia and Hypertension. Review of Patient #3's Hospice Certification and Plan of Care with a certification period of 4/12/2022-7/10/2022 showed "...Monitor pain level using pain scale each visit and report changes in pain level to physician..." Record review showed Patient #3 received Skilled Nursing (SN) visits on 4/13/2022, 4/19/2022, and 4/26/2022 pain assessments showed the patients pain severity was "...0..." indicating no pain. A SN visit on 5/3/2022 showed Patient #3 reported a pain severity of "...mild..." indicating the patient had an increase in pain. Record review revealed the physician had not been notified of the increase in pain. During an interview on 6/22/2022 at 8:58 AM, the Director of Clinical Services confirmed Patient #3's increase in pain on 5/3/2022 had not been reported to the physician. Patient #4 was admitted to the agency on 2/10/2022 with diagnoses to include Cerebral Infarction, Major Depressive Disorder, and Cerebrovascular Disease. Record review showed Patient #4 received SN visits on 5/11/2022, and 5/18/2022 pain assessments showed the patients pain severity was "...0..." indicating no pain. A SN visit on 5/24/2022 showed Patient #4 reported a pain severity of "...mild..." indicating the patient had an increase in pain. Record review revealed the physician had not been notified of the increase in pain. During an interview on 6/22/2022 at 10:15 AM, the Director of Clinical Services stated Patient #4 had an increase in pain on 5/24/2022 and the physician had not been notified of the patients change in condition.

Based on agency policy review, medical record review, and interview the agency failed to communicate to the Interdisciplinary Group (IDG) of missed visits for 3 patients (#1, #2, and #3) of 13 patients reviewed. The findings include: Review of the facility's policy titled, "Missed Visits," revised 5/11/2020, showed "...Missed visits will be communicated to the Interdisciplinary Group (IDG) at the IDG meeting...If a visit is missed for any reason...Notify the IDG...of the missed visit and reason for missed visit..." Patient #1 was admitted to the agency on 11/18/2021 with diagnoses to include Alzheimer's Disease, Repeated Falls, and Adult Failure to Thrive. Review of Patient #1's Hospice Certification and Plan of Care for recertification period 5/17/2022-7/15/2022, showed the patient was to receive a Skilled Nurse (SN) and Hospice Home Aide (HHA) visit 2 times a week for 9 weeks effective 5/17/2022. Review of the medical record showed Patient #1 had a SN and HHA missed visit on 5/30/2022. The IDG had not been notified of the missed visits. Patient #2 was admitted to the agency on 1/4/2021 with diagnoses to include Vascular Dementia, Alzheimer's Disease, and Anxiety Disorder. Review of Patient #2's Hospice Certification and Plan of Care for recertification period 4/29/2022-6/27/2022, showed the patient was to receive a SN visit 2 times a week for 8 weeks effective 4/29/2022 and a HHA visit 2 times a week for 8 weeks effective 5/1/2022. Review of the medical record showed Patient #2 had a missed SN missed visit on 5/30/2022 and a HHA missed visit on 5/31/2022. The IDG had not been notified of the missed visits. Patient #3 was admitted to the agency on 5/22/2022 with diagnoses to include Chronic Obstructive Pulmonary Disease, Pulmonary Hypertension, and Major Depressive Disorder. Review of Patient #3's Hospice Certification and Plan of Care for recertification period 5/22/2022-8/19/2022, showed the patient was to receive a SN and a HHA visit 2 times a week. Review of the medical record showed Patient #3 had a SN missed visit on 5/30/2022 and the IDG had not been notified of the missed visit. During an interview on 6/22/2022 at 9:11 AM the Administrator confirmed the IDG had not been notified of the missed visits for Patient's #1 and #2. During an interview on 6/22/2022 at 9:29 AM, the Director of Clinical Services confirmed the missed visits are not communicated during the IDG meetings.

Based on facility policy review, medical record review, and interview the agency failed to obtain a Physician's Order for wound care for 1 patient #7 of 13 patients reviewed. The findings include: Review of the facility's policy titled, "Wound Care," revised 5/11/2020, showed "...All wound care will be performed in accordance with physician orders..." Patient #7 was admitted to the agency on 6/9/2022 with diagnoses to include Peripheral Vascular Disease, Protein Calorie Nutrition, Dementia. Review of the medical record showed Patient #7 had an initial nursing assessment dated 6/9/2022 which identified a venous stasis ulcer to the lower left front of the leg. The wound is documented as a Venous Stasis Ulcer. Further review showed there was not a Physician's Order for wound care. During an interview on 6/22/2022 at 9:55 AM, the Director of Clinical Services confirmed Patient #7 did not have a Physician's Order for wound care. During a telephone interview on 6/22/2022 at 5:27 PM, Registered Nurse #1 stated she was the regular nurse for Patient #7. The patient has a wound to the lower left leg and RN #1 had treated the wound. She confirmed Resident #7 had not had a Physician's Order for wound care until 6/22/2022. She also stated she assessed the resident on 6/22/2022, the wound had improved, and wound care is provided weekly.