Every finding on record at Advantage Health Systems

Observed in Record Review. In 14 of 16 patient records reviewed, of those patients who were receiving MSW or Chaplain services the hospice surveyor noted that the plan of care did not have individualized care plans and the time frames all stated at the end of the certification period. In HOSRRHV #1 the MSW care plan stated Patient/family/caregiver communication needs met throughout the certification period. HOSRRNHV#4, HOSRRNHV #8, HOSRRNHV #9, and HOSRRHV #2 the MSW care plan stated Patient/family/caregiver will be emotionally supported during the terminal illness throughout the certification period. The chaplain care plan stated, Patient/family/caregiver will receive desired spiritual support throughout the certification period. In HOSRRNHV #6, HOSRRNHV #7, the Chaplain care plan stated, Patient/family/caregiver will receive desired spiritual support throughout the certification period. In HOSRRNHV #10 and HOSRRDC #2 the MSW care plan stated Patient/family/caregiver would be emotionally supported during patient terminal illness throughout the benefit period. In HOSRRHV #2 and HOSRRHV #3 the MSW care plan stated Patient/family/caregiver communication needs are met throughout the benefit period. The Chaplain care plan stated Patient/Family/Caregiver will verbalize spiritual conflicts and demonstrate resolution throughout the certification period. In HOSRRHV #4 the MSW care plan stated Patient/family/Caregiver communications needs are met throughout the benefit period. In HOSRRNHV #1 both the Chaplain and MSW care plans stated Patient/family/caregiver communication needs are met throughout the benefit period. In HOSRRNHV #2 the MSW care plan stated Caregiver maintains physical and emotional health throughout the benefit period. In HOSRRDC #1 MSW care plan stated Patient/family/caregiver anxiety is minimized within limits of disease progression throughout the certification period and the Chaplain care plan stated Patient/family/caregiver communication needs are met throughout the certification period. The organization failed to individualize the patient's plan of care. This was reviewed and validated with the DPCS. Observed in Record Review. In 13 of 16 patient records reviewed, the hospice surveyor noted that during HOSRRHV #1, HOSRRHV #2, HOSRRHV #3, HOSRRHV #4, HOSRRNHV #1, HOSRRNHV #2, HOSRRNHV #7, HOSRRNHV #8, HOSRRNHV #9, and HOSRRNHV #10, the patients had a care plan for pain which states the patient will maintain an acceptable pain level; of 0-3/10 throughout the cert period of 60 days, which was the same goal for all patients. There were no patient-specific goals. This was a nursing goal. For example, in HOSRRNHV #3 the nurse utilized a verbal tool to assess pain, there was no self-reported goal entered in the assessment. However, the care plan used was an observational tool goal; the patient will have decreased moaning, which was from the FLACC or PAINAD scales. Per the comprehensive assessment, the nurse used an observational pain tool and the patient was deemed to not have any pain. Another example is HOSRRHV #1 patient has a stage 1 pressure injury and the care plan goal states the patient's skin remains intact within the limits of the disease process throughout the certification period. In HHRRDC #1 the pain goal states Pt/family/caregiver to establish desired pain goal throughout the certification period. There was no patient goal established, and the nurse used an observational tool to assess pain. HOSRRDC #2 the nurse used a verbal descriptor to assess the patient but did not document the patient's pain goal. The care plan stated, Patient/family/caregiver pain is controlled within their desired comfort level during the certification period. The plans of care were not individualized with regard to goals and timeframes to meet the patient's needs. This was reviewed and validated with the DPCS.

Observed in Record Review. In 7 of 16 patient records reviewed, the hospice surveyor noted that HOSRRHV #1, HOSRRHV #3, HOSRRNHV #3, HOSRRNHV #4, and HOSRRNHV #10 the patient had both Acetaminophen suppository 650 mg every 4 hours as needed for pain and there was also an order for Roxanol oral solution 20 mg/ml 5 ml every 2 hour as needed for mild pain. In HOSRRNHV #1 there was an order for Tylenol with codeine 300-3 1 po TID as needed for pain, acetaminophen 650 mg suppository every 4 hours as needed for mild pain, MSIR 15 mg, 1/2 tab q 4 hrs. and Morphine sulfate 20 mg/ml 5 ml every 2 hours as needed for mild pain. In HOSRRNHV #2 there was an order for Morphine Sulfate 10 mg every 2 hours po for moderate pain, Hydrocodone Acetaminophen 5-325 mg three times a day po moderate pain as well as Morphine Sulfate 5 mg every 2 hours as needed for mild pain and Acetaminophen supp 650 mg every 4 hours as needed for mild pain. The plan of care orders include duplicate orders for medication for moderate and mild pain. This was reviewed and validated with the DCPS.

Observed in Record Review. In 1 of 16 patient records reviewed, the hospice surveyor noted there was an order for oxygen but there was no liter flow added. The order was incomplete. This was reviewed and validated with the DPCS. Observed in Record Review. In 6 of 16 patient records reviewed, the Hospice surveyor noted in HOSRRHV #2, HOSRRHV #4, HOSRRNHV #1, HOSRRNHV #5, HOSRRNHV #6, that the patient had an order for oxygen 2-4 liters via nasal canula prn for SOB. In HOSRRNHV #3 the order for oxygen was 2-5 liters via nasal cannula continuous. The RN failed to document when the patient should use 2, 3, 4 and in one instance 5 liters of oxygen. The Identification of Medication for Administration policy states the nurse will not administer medications and will clarify orders with the physician or licensed practitioner if the medication order is incomplete, illegible or unclear. The oxygen order is not clear as there are no instructions for the patient on when to titrate up the oxygen. This was reviewed and validated with the DCPS.

Observed in Record Review. In 4 of 15 patient records reviewed, of the patients who received home health aide services the surveyor noted that in HOSRRHV #1 the home health aide was ordered for two times per week, but in January, March, May, and April 2025 there was one missed visit for each of those months. In HOSRRNHV #6 the home health aide was ordered for twice per week but during December 2024 and January 2025 she missed a visit each month and the provider was not notified. In HOSRRNHV #9 the home health aide was ordered for twice a week and she missed a visit in May 2025 and the provider was not notified. In HOSRRNHV #10 the aide was ordered for three times per week and she missed a visit in December and January. The provider was not notified of the missed visits. This was reviewed and validated with the Director of Patient Care Services Observed in Record Review. In 1 of 16 patient records reviewed, the hospice surveyor noted that HOSRRNHV #2 had an order for foley catheter changes every month and as needed and for catheter flushes every 2 weeks and as needed and the charting did not show a catheter change or flushes in the last 2 months. The organization failed to change the indwelling catheter or provide the ordered flushes per the doctors orders. This was reviewed and validated with the DPCS.

Observed in Tracer Activities. The organization failed to compile, trend or analyze data related to the QAPI program. The Hospice surveyor noted that the organization collected data on hand hygiene, respiratory infections, urinary tract infections, and falls but none of the data was trended over one year or analyzed for process improvement. This was reviewed and validated with the DCPS.

Observed in Patient Home. In 1 of 4 home visits conducted, the surveyor noted that the RN failed to follow the manufacturer's guidelines for cleaning the Homedics electronic blood pressure cuff that the organization provided. The manufacturer's guidelines state that the cuff must be cleaned with a damp soft cloth and that the cuff should never be cleaned with thinner, alcohol, or petrol products.. The RN used ETOH 75% wipes on her cuff. This was reviewed and validated with the DPCS.

Observed in Tracer Activities. In 1 of 1 HR files reviewed, for the home health aide there were only 10 hours of in-service training in last 12 months documented. This was reviewed and validated with the HR Director.

Observed in Record Review. In 10 of 14 patient records reviewed, where the home health aide was ordered the hospice surveyor noted that in HOSRRHV #3 that the aide care plan failed to include fall and aspiration precautions. In HOSRRHV #4 the home health care plan does not include aspiration risk. In HOSRRNHV #1 patient diagnosed with CRE and no infection or aspiration precautions added to the aide plan of care. In HOSRRNHV #4 and in HOSRRNHV #8 the home health aide care plan does not include bleeding precautions as the patient was on an anticoagulant. In HOSRRNHV #6 HOSRRDC #2 the patient was deemed a fall and bleeding risk due to anticoagulation therapy but this was not entered into the home health aides care plan. In HOSRRNHV #7 the patient was assessed as a fall risk, bleeding precautions, and an aspiration risk and none were added to the aide care plan as precautions. In HOSRRNHV #9 the patient had seizure precautions and this was not added to the home health aide care plan. In HOSRRDC #1 the home health aide care plan did not include aspiration precautions. The organization failed to plan the patient's care as the home health aide was not informed of the safety precautions for these patients. This was reviewed and validated with the DPCS.

Observed in Tracer Activities. In 3 of 4 HR files reviewed, where there was a medical provider the hospice surveyor noted that the Alternate Medical Directors #3, #9, and #10 did not have an initial competency in their files. This was reviewed and validated with the HR Director.

Observed in HR File Review. In 2 of 4 HR files reviewed, where there were medical directors the surveyor noted that both HR #9 and HR #10 alternate medical directors did not have a criminal background check conducted or documented per HCO policy at hire. This was reviewed and validated with the HR Director.

Observed in Record Review. In 3 of 15 patient records reviewed, the initial bereavement assessment was not completed. In RR #6, RR #7, and BR #2. The Hospice Surveyor noted the bereavement risk assessment was not completed as part of the comprehensive assessment. This was reviewed, discussed, and confirmed with the bereavement coordinator.

Observed in Record Review. In 13 out of 13 patient records reviewed, the hospice did not ensure the patient's goals were individualized and measurable. Examples include the following: patient will be at an acceptable pain level; patient will experience a peaceful death with symptoms managed and the time frame for all goals was documented as within two weeks or at the end of the certification period. These stated goals do not contain specific information that can be accurately measured to assist organizational staff in determining whether the patient is progressing towards achieving their goals. This was reviewed and validated with the Hospice Administrator.

Observed in Tracer Activities. Upon review of the organization's quality plan, the agency hospice QAPI program was not evaluated annually. What was provided for review was a summary of three adverse events, measuring a three-month period. This was reviewed, discussed, and validated by the hospice administrator.

Observed in Patient Home. In 5 of 13 patient records reviewed, the hospice aide care plan did not provide specific directions for ADL/personal care. For example, in HV #1/RR #1 and RR #6 the directions for oxygen/use during care were not included, RR #4 did not include parameters to notify the patient's nurse regarding a head wound dressing, RR # 7 did provide specific directions for transferring patient. This was reviewed, discussed and verified by the DON.