Every finding on record at Adventa Hospice, L.L.C.

Upon patient record review, 3 of 19 (Patient #3,#4,#8) 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 3,4, 8:The medication profile includes an entry for oxygen. The entry does not include the route of administration.

Upon patient record review, 1 of 19 (Patient #5) 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 5:The patient was admitted on 8/7/24. There is no evidence of a bereavement risk assessment prior to 8/15/24.

Upon patient record review, 5 of 19 (Patient #1,#2,#3,#5,#13) 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 and 2:The medical record includes nursing documentation that the patient is at risk for aspiration. There is no evidence that the plan of care includes problems, goals and interventions to manage the risk of aspiration. Patient 3:The medical record includes nursing documentation that the patient was admitted with a supra pubic catheter. There is no evidence that the plan of care includes problems, goals and interventions for the management of the catheter. Patient 5:The medical record includes nursing documentation that the patient is on a pureed diet and is at risk for aspiration and falls and requires the use of a Hoyer lift and suction equipment. There is no evidence that the plan of care includes problems, goals and interventions to manage the risk of aspiration and falls and the use of a Hoyer lift and suction equipment. Patient 13:The medical record includes nursing documentation that the patient is at risk for bleeding/hemorrhage due to a recent history of a gastrointestinal bleed. There is no evidence that the plan of care includes problems, goals and interventions to manage the potential for bleeding/hemorrhage.

Upon patient record review, 3 of 19 (Patient #4,#6,#7) 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:The plan of care includes an order for oxygen. There is no evidence that the order includes the route of administration. Patient 6:The plan of care includes an order dated 8/1/24 for debrox to be used daily for ear wax removal with no end date. Patient 7:The medical records includes nursing documentation that the patient requires oxygen to be used at 2 liters per minute as needed for shortness of breath. There is no evidence that the plan of care includes an order for oxygen.

Upon patient record review, 2 of 19 (Patient #3, #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 equipment and supply needs. Patient 3:The medical record contained nursing documentation on admission that the patient required a wheelchair for mobility. There is no evidence of a wheelchair included on the equipment and supply needs. COS Patient 4:The medical record contained nursing documentation on admission that the patient required a hospital bed and a wheelchair for mobility. There is no evidence of a hospital bed and wheelchair included on the equipment and supply needs.

Upon client record review, 2 of 19 (Patient #6, 10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 6: The medical records contains nursing documentation on 8/23/24 that the patient was placed on oxygen due to low oxygen saturations. There is no evidence that the plan of care includes an order for oxygen. Patient 10: The medical record includes nursing documentation on 8/24/24 that the patient was catheterized due to urinary retention. There is no evidence that the plan of care includes an order for the patient to be catheterized.

Upon patient record review, 4 of 19 (Patient #1,#3,#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 1 and 3:The plan of care includes fall, aspiration and oxygen precautions. The aide plan of care does not include fall, aspiration or oxygen precautions. Patient 12:The plan of care includes universal and fall precautions. The Aide plan of care does not include universal and fall precautions. Patient 13:The plan of care includes bleeding, oxygen and fall precautions. The Aide plan of care does not include bleeding, oxygen and fall precautions.

Upon patient record review, 4 of 13 (Patient #1, #3, #4, #6) did not have evidence in the patient record that a complete review of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy was performed. Patient #1- On 10/28/21 the nurse documented the patient's heartburn is controlled with TUMs. On 11/05/21 the nurse documents the patient is taking Miralax. TUMs and Miralax are not listed on the medication profile. Patient #3-The patient was admitted on Oxygen. The patient is receiving Heparin and Saline flushes for PICC line maintenance. Oxygen, Heparin and Saline are not listed on the medication profile. Patient #4- The medication profile contains Nitroglycerin .4mg SL q5min times 3 prn per instructions. Indications for prn dosing are not specified in orders. Patient #6-The medication profile includes Oxygen prn per instructions for shortness of breath or hypoxia. A liter flow is not included.

Upon patient record review, 1 of 13 (Patient #1) 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. Patient #1- Between 10/25/21 and 11/25/21 the nurse consistently documented in visit notes that the patient was having problems with constipation. The plan of care/goals were not updated with alteration in GI status/ constipation. Additionally on 11/08/21, the patient signed a DNR and the DNR was not updated on the plan of care. (corrected on site)

Upon patient record review, 9 of 13 (Patient #1, #2, #3, #4, #5, #6, #7, #9, #12) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including specific orders for all medications and treatments. Patient #1- On 10/28/21, the nurse documented the patient's heartburn is controlled with TUMs. On 11/05/21, the nurse documents the patient is taking Miralax. TUMs and Miralax are not listed on the plan of care. Patient #2- On 10/18/21, the nurse documented performing wound care to the patients Rt knee abrasion and on 10/29/21 the nurse documented performing wound care to the patients left arm skin tear. Orders for wound care were not updated on the plan of care. Patient #3-The patient was admitted on Oxygen. Oxygen liter flow and frequency is not included in the plan of care. The patient is receiving Heparin and Saline flushes for PICC line maintenance. Heparin and Saline are not listed on the plan of care. 11/15/21 orders to update the plan of care read : SN to care for access device. The orders are not specific for PICC line dressing changes and flushes to be performed. 11/15/21 orders read SN to instruct patient in fistula site management. including appliance type, usage and stomal care. The orders are not specific for the actual fistula/stomal care to be rendered. Patient #4- The 08/27/21 plan of care includes orders for Nitroglycerin .4mg SL q5min times 3 prn per instructions. Indications for prn dosing are not specified in orders. Patient #5- The plan of care includes orders for skilled nurse to instruct/insert 14 Fr straight catheter 4 times daily and prn. Indications for prn are not specified in the orders. Patient #6-The10/19/21 plan of care includes Oxygen prn per instructions for shortness of breath or hypoxia. A liter flow is not included. Patient #7- The 08/20/21 plan of care lists nutritional requirement as tube feedings. The plan of care orders are incomplete and read as follows: SN to perform/instruct in gastrostomy tube feedings including preparation/administration of feedings Type/cc/hr via (pump or bolus) Type cans frequency flush gastrostomy with cc of frequency, site care, check residual every. The specific type and administration of feedings as well as site care and residual checks were not completed in the plan of care. Patient #9-The 04/14/21 plan of care includes orders to perform site care to the Mediport as follows: Dressing change once a week and prn when loose or soiled. The orders are not specific for they type of dressing change to be performed. Patient #12- On 10/31/21 an order was written to update the plan of care to insert a Foley catheter and change monthly. The order does not include the size/balloon size.

Upon client record review, 1 of 13 (Patient #9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #9- The orders on record are for nursing to change the patients Foley catheter monthly with a 16 Fr catheter. On 05/01/21 the nurse documented changing the catheter using an 18 Fr Foley.

Upon patient record review, 1 of 1 applicable (Patient #9) did not have evidence the hospice delivers bereavement services in accordance with the plan of care. Patient #9: The patient died 05/19/21 and was scheduled to receive a bereavement phone call on 05/24/21 and 11/19/21. There is no documentation on record to evidence the calls were made. The patient was scheduled for mailings on 05/21/21 , 06/15/21 and 08/14/21 and there is no documentation on record that the mailings were sent.

Upon personnel record review, 1 of 1 applicable (Personnel #6) did not have evidence in the personnel file that a complete competency assessment was performed by the aide with a patient. Personnel #6: The Aide has competencies on record 04-30-20 and 10-17-21. The competencies do not evidence the aide has been observed performing a tub and shower bath or a shampoo in the sink or bed

Upon patient record review 1 of 6 (Patient #2) did not evidence documentation in the patient record that a hospice aide provides services that are included in the plan of care. Patient #2-The Aide was assigned to visit the patient twice weekly for twelve weeks beginning 10/14/21. The aide was noted to visit only once the week of 11/7/21 (11/11/21) and week of 11/14/21 (11/18/21). There was no missed visit documentation noted for the second visits ordered to be made those weeks.

Upon patient record review, 5 of 13 (Patient #1, #2, #3, #9, #12) did not have evidence that all entries are complete and accurate. Patient #1- On 11/17/21 the IDG documented the patient is a Full Code. This was an error in documentation as the patient signed a DNR 11/08/21. Patient #2 - Aide missed visit documentation noted for missed visits on 10/18/21, 10/28/21 but the missed visit documentation did not include the reason for the missed visit. Patient #3- On 10/08/21 the nurse documented the patients PICC line was flushed without difficulty. The documentation is not specific for the actual flushes administered. On 10/18/21 the nurse documented labs were drawn. The documentation is not specific for the type of lab work to be performed. On 11/08/21 the nurse documented PICC line flushed with Q0ml saline (documentation error) and 3ml Heparin. Heparin dosage/concentration units/cc is not documented. On 11/15/21 the nurse documents the patients PICC line dressing was changed. The documentation is not specific for the actual dressing procedure performed. On 11/15/21 the nurse documented the patients ileostomy bag was changed. This is a documentation error as the patient had a ostomy bag applied over a fistula (not ileostomy) which formed at an old PEG site. Patient #9-On 04/18/21 the nurse documents administering Morphine per orders following wound care procedure. The documentation is not specific for the actual dosage of Morphine administered. On 04/25/21 and 05/03/21 the nurse documents flushing the patients port site and documentation is not specific for actual flushes administered. Patient #12- On 10/31/21 the nurse documented the patient was administered prn Morphine during visit. The documentation is not specific for the dose administered.