Every finding on record at Adventa Hospice, LLC

Upon patient record review, 3 of 19 (Patient #1,5,7) 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: There is evidence in the medical record of a wound order on 12/12/24 with Bacitracin. Bacitracin is not on medication sheet. Patient #5: Observed during home visit, Lorazepam is on the hospice medication profile was not on facility medication sheet. Patient #7 Observed during home visit, Ibuprofen on hospice medication profile was not on patient home medication sheet. Patient discontinued the medication in November, 2024

Upon patient record review, 2 of 19 (Patient #4,6) 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: There is an order for wound care on 12/16/24. The order does not include who will change the dressing or how often. Patient #6: Nurse notes on 12/31/24, "patient has blisters on back. Blisters have broken, wife is putting betadine on blisters". There is no order for treatment.

Upon patient record review, 4 of 19 (Patient #1,2,4,6) 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 #1: There is evidence in the medical record, nurse notes on 12/10/24, Edema 2+ bilateral legs and new order for Lasix and Spironolactone. There is not a plan of care update for edema.. Patient #2: There is evidence in the medical record, patient had covid in previous benefit period as documented on physician CTI and Nurses RN assessment 10/15/24. There was not a plan of care update for COVID. Patient #4: There is evidence in the medical record, patient started on antibiotic on 12/16/24 for 7 days and then on 12/23/24 there was an order for Cephalexin daily for UTI prophylaxis. There was not a plan of care update for infection. Patient: #6: There is evidence in the medical record, patient started on nebulizer treatment on 12/20/24, there is not a plan of care update for inhalation treatment.

Upon patient record review 1 of 19 (Patient #4) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #4: There is evidence in the medical record of a note by the Chaplain patient indicating a request for PT and the status of DME . Note states MSW will follow up. There is no documentation of coordination with the RNCM regarding Physical therapy or the status of DME.

Upon patient record review, 2 of 19 (Patient #2,3) 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 #2: Aide plan of care on 11/4/24, lists assist with shower chair every visit and assist with bed bath every visit. Task is not specific. Additionally, the patient is on aspiration precautions on the plan of care and this does not appear on the aide plan of care. Patient #3: patient is on aspiration precautions on the plan of care and this does not appear on the aide plan of care.

Upon patient record review 1 of 19 (Patient #8) 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 #8: The aide plan of care indicates shave weekly. The week of 12/23/24, the aide shaved the patient both visits.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. There is evidence in the Volunteer Cost Savings Report equals less than 1 percent of total patient care hours. (Corporate PIP in progress)

Based on record review and staff interview, it was determined that the agency failed to provide information about the services covered under the hospice benefit for one (1) of fourteen (14) sampled patients(P) (P#3). The finding include: Patient #3 was admitted to hospice on 7/22/21, with a diagnosis of senile degeneration of brain, hypertension, and atrial fibrillation. On 3/16/22, at 2:30 p.m., during the home visit Patient #3's family stated, the hospice agency did not inform or explain to them that hospice benefit respite care was available for them if needed. P#3's wife said they went to Veterans Administration for respite care. On 3/16/22, at 3:20 p.m., an interview was conducted with Administrator who confirmed she spoke with P#3's family on 3/16/22, after meeting with the surveyor and she was surprised P#3's family were not informed that respite care was available if needed.

Based on review of clinical records, it was determined the interdisciplinary group failed to ensure the comprehensive assessment was completed within 5 days of admission for two (2) of fourteen (14) sampled patients (P) (P#1, and P#14). The findings Include: 1. Review of the clinical record P#1 was admitted on 12/1/21, with a diagnosed of Parkinson's disease, hypertension, sleep apnea, and cardiac pacemaker. The initial psychosocial assessment was completed on 12/10/21, nine days after the patient's admission. The clinical record did not include documentation regarding the staff's delay in completing the assessments. 2. Review of the clinical record P#14 was admitted on 12/29/21, with a diagnosis of Alzheimer's disease, dementia, hypertensive heart disease and type 2 diabetes. The initial psychosocial assessment was completed on 1/4/22, six days after P#14's admission. The clinical record did not include documentation regarding the staff's delay in completing the assessments. During an interview on 3/16/22, at 9:15 a.m., the Administrator stated, they have two social workers, and both of them were on medical leave. The Administrator confirmed the surveyor had been provided with all available documentation for the patients' record.

Based on observation, clinical record review, and staff interviews it was determined the agency failed to ensure patient medication profiles were updated to reflect current medications at the time of the comprehensive assessment for two (2) of fourteen (14) sampled patients (P) (P#1 and P#2). The findings include: 1. During a home visit for Patient #1 on 3/16/22, at approximately 10:00 a.m., with Registered Nurse (RN) AA it was revealed that P#1 was admitted on 12/1/21, with a diagnosis of Parkinson's disease, hypertension, sleep apnea, and cardiac pacemaker. The surveyor compared P#1's current medication list at home to the hospice agency's medication profile and discrepancies were found. The following medications were missing from P#1's hospice medication profile and plan of care: -Armodafinil 150 milligrams (MG), take one tablet oral daily for sleep disorder, filled on 3/10/22. -Vitamin D3 50 microgram (MCG), take one capsule oral daily used for bone supplement for over one year. Hospice agency medication profile and plan of care included: -Benadryl 25mg take one capsule oral at bedtime, the pharmacy label was for Benadryl 25mg take one capsule oral every four to six hours as needed for sleep aid, filled on 1/5/22. - Rytary 48.75 mg-195mg extended release take one capsule oral daily, the pharmacy label was to take three times daily, filled on 2/19/22. On 3/16/22, at 11:30 a.m., an interview was conducted with RN AA, who stated, "I do not know how I missed the above medications." 2. During a home visit for Patient #2 on 3/16/22, at approximately 1:00 p.m., with Registered Nurse (RN) BB, it was revealed that P#2 was admitted on 9/23/20, with a diagnosis of senile degeneration of brain disease, dementia, major depressive disorder, general anxiety disorder, mixed incontinence, irritable bowel disease, hypothyroidism, altered mental status, nausea and vomiting. There were discrepancies in the medication profile and plan of care for P#2's home medications. The hospice agency's medication profile and plan of care revealed: -Acetaminophen extra strength 500mg take two tablets oral two times daily, the medication container read acetaminophen 650mg take one tablet oral twice daily. -Protonix 20mg delayed release take one tablet oral daily, pharmacy label was Protonix 40mg take one tablet oral at bedtime use for acid reflux. -Senna-S 8.6mg-50mg take one to two tablets daily oral use for constipation was discontinued six months ago but continues to be listed on medication profile and plan of care. - Lorazepam Intensol 2mg/ml give 0.5-milliliters (ML) every four hours oral use for agitation and anxiety, the medication was filled on 9/23/20, and expired on 9/23/21. -Morphine concentrate 100mg/5ml (20mg/ml) oral solution give 0.25ml every two hours for pain or dyspnea the medications was filled on 9/24/20, and expired on 9/24/21. -Tramadol 50mg give one tablet oral every six hours for pain, the medication was filled on 3/2/21, and expired expired on 3/2/22. The above-listed medications were taken by P#2 on 3/14/22, this was confirmed by P#2's family and caregiver. On 3/16/22, at 1:40 p.m., an interview was conducted with Registered Nurse RN BB, who confirmed he did not check the medications containers and did not update the medication profile or the plan of care.

Based on observation, clinical record review, and staff interviews it was determined the agency failed to ensure patient's plan of care was updated to reflect current medications at the time of the comprehensive assessment for two (2) of fourteen (14) sampled patients (P) (P#1 and P#2). The findings include: 1. During a home visit observation conducted on 3/16/22, at approximately 10:00 a.m., with Registered Nurse (RN) AA for P#1 with an admission date of 12/1/21, and diagnosis of Parkinson's disease, hypertension, sleep apnea, and cardiac pacemaker. The surveyor compared P#1's current medication list at home to the hospice agency's plan of care. The following medications were missing from P#1's hospice plan of care. - Armodafinil 150 milligrams (MG), take one tablet oral daily for sleep disorder, it was filled on 3/10/22. - Vitamin D3 50 microgram (MCG), take one capsule oral daily used for bone supplement for over one year. The current plan of care included P#1's home medications. - Benadryl 25mg take one capsule oral at bedtime; the pharmacy label read Benadryl 25mg take one capsule oral every four to six hours as needed for sleep aid, filled 1/5/22. - Rytary 48.75 mg-195mg extended release take one capsule oral daily, the pharmacy label read take three times daily, filled on 2/19/22. On 3/16/22, at 11:30 a.m., an interview was conducted with RN AA who stated, "I do not know how I missed the above medications". 2. During a home visit for Patient #2 on 3/16/22, at approximately 1:00 p.m., with Registered Nurse (RN) BB it was revealed P#2 was admitted on 9/23/20, with a diagnosis of senile degeneration of brain disease, dementia, major depressive disorder, general anxiety disorder, mixed incontinence, irritable bowel disease, hypothyroidism, altered mental status, nausea and vomiting. There were discrepancies in plan of care for P#2's home medications. The hospice agency plan of care revealed: - Acetaminophen extra strength 500mg take two tablets oral two times daily, the medication container was labeled acetaminophen 650mg take one tablet oral twice daily. -Protonix 20mg delayed release take one tablet oral daily; the pharmacy label read Protonix 40mg take one tablet oral at bedtime use for acid reflux. - Senna-S 8.6mg-50mg take one to two tablets daily oral use for constipation was discontinued six months ago, listed on medication profile and plan of care. - Lorazepam Intensol 2mg/ml give 0.5-milliliters (ML) every four hours oral use for agitation and anxiety, the medicaiton was filled on 9/23/20, and expired on 9/23/21. -Morphine concentrate 100mg/5ml (20mg/ml) oral solution give 0.25ml every two hours for pain or dyspnea, the medication was filled on 9/24/20, and expired on 9/24/21. -Tramadol 50mg give one tablet oral every six hours for pain, the medication was filled on 3/2/21, and expired on 3/2/22. The above-listed medications were taken by P#2 on 3/14/22. This was confirmed by P#2's family and caregiver. On 3/16/22, at 1:40 p.m., an interview was conducted with RN BB who confirmed he did not check the medications containers and did not update the plan of care.

Based on home visit observations, and staff interviews it was determined that the hospice agency staff failed to follow standard precautions to prevent the transmission of infectious and communicable diseases during a bed bath for one (1) of fourteen (14) patients (P) (P#3). The findings include: Patient #3 was admitted to hospice on 7/22/21, with a diagnosis of senile degeneration of brain, hypertension,and atrial fibrillation. During a home visit with P#3 on 3/16/22, at 2:45 p.m., the surveyor observed Certified Nursing Aide (CNA) CC, perform bed bath care to P#3. During the entire bathing procedure CNA CC did not change gloves or the water and did not use sanitizer or wash her hands. CNA CC dropped the washcloth and towel on the floor after completing the bath. On 3/16/22, at 3:00 p.m., an interview was conducted with CNA CC, she comfirmed that she did not change gloves and did not change the bath water. CNA CC said, she was nervous during the bathing procedure. During an interview on 3/16/21, at 4:00 p.m., the Administrator acknowledged CNA CC did not follow acceptable standards for infection control to prevent transmission of infectious and communicable diseases.

Based on observation, clinical record review, and staff interviews, it was determined the agency failed to ensure patients' medication (Morphine and Levsin) were available 24 hours 7 days a week for one (1) of fourteen (14) sampled patients (P) (P#1). The finding include: During a home visit observation conducted on 3/16/22, at approximately 10:00 a.m., with Registered Nurse (RN) AA, for P#1 revealed an admission date on 12/1/21, with a diagnosis of Parkinson's disease, hypertension, sleep apnea, and cardiac pacemaker. The surveyor compared P#1's current medication list at home to the hospice agency's medication profile. Discrepancies were found. P#1's medications were Morphine Concentrate 100 milligrams (MG), /5milliliters (ML), (20mg/ml) oral solution give 0.25-1ml every two hours as needed for pain or shortness of breath; and Levsin sublingual 0.125mg give one tablet sublingual every four hours as needed for secretions both medications were not ordered from the pharmacy by RN AA. On 3/16/22, at 10:40 a.m., an interview was conducted with RN AA, who stated, "they must get it from the pharmacy when they need it. They don't need it now". On 3/16/22, at 11:05 a.m., an interview was conducted with Administrator (Director of Operation) and Assistant Vice President (AVP) both stated, they believe that medication was denied being in the home. The AVP stated, "The medication can expire, that's why with some patients we wait until they need it."

Based on clinical record review and staff interview, it was determined that the agency failed to obtain physician orders for durable medical equipment (DME) for one of fourteen (14) sampled patients (P) (P#3). The findings include: Patient #3 was admitted to hospice on 7/22/21, with a diagnosis of senile degeneration of brain, hypertension,and atrial fibrillation. Review of the initial Skilled Nurse (SN) assessment and plan of care (POC) dated 7/30/21, revealed P#3 had a hospital bed, wheelchair, bed commode and rolling walker. During review of the clinical record, it was discovered there was no physician order for hospital bed, wheelchair, bed commode and rolling walker. During an interview on 3/16/22, at 2:50 p.m., the Administrator confirmed the agency did not have orders for the DME listed above.

Based on record review and staff interview, it was determined the agency failed to provide drugs and biological's related to the management and palliation of terminal illness and related conditions identified on patients' hospice plan of care. The agency failed to provide the needed medications related to the co morbidities in four (4) of fourteen (14) sampled patients (P) (P#4, P#6, P#7 and P#8). The findings include: 1. Clinical records for P#4 was reviewed for certification date 3/8/22 to 5/6/22. P#4 was admitted to hospice services on 9/20/19, with a primary diagnosis of Parkinson's disease, with the following co morbidities: atherosclerosis heart disease of native coronary artery, essential hypertension and hypothyroidism. The record showed the agency was not providing coverage for payment for the following medications used to manage the co morbidities: -Aspirin 81milligrams (MG) one tablet oral daily for heart protection (anticoagulant). -Levothyroxine 25micrograms (MCG) one tablet oral daily for thyroid disease. During the home visit with P#4 and a family member who stated, "he was taking the medications but they were not being ordered or paid for by the hospice agency." 2. Clinical records for P#6 who expired on 1/26/22, was reviewed for certification date 12/24/21 to 2/21/22. P#6 was admitted to hospice services on 10/31/21, with a primary diagnosis of chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, anxiety, dyspnea, and muscle weakness. The record showed the agency was not providing coverage for payment for the following medications used to manage the co morbidities: -Amlodipine 5mg take one tablet oral daily for hypertension. -Baclofen 5mg take one tablet oral three times daily for muscle spasms. -Cetirizine 10mg take one tablet at bedtime for respiratory allergies. -Flonase allergy relief 50mcg/actuation nasal spray suspension one spray daily for respiratory allergy. 3. Clinical records for P#7 who expired on 12/18/21, with a certification date 10/31/21 to 1/28/22. Per the patient's plan of care, the patient was admitted to hospice services on 10/31/21, with a primary diagnosis of chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, chronic kidney disease anemia, generalized edema, chronic respiratory failure with hypoxia, and chronic atrial fibrillation. The record showed the agency was not providing coverage for payment for the following medications used to manage the co morbidities: -Ergocalciferol (Vitamin D2) 1,250mcg (50,000units) capsule give one capsule oral weekly for electrolyte imbalance supplement. -Ferrous Sulfate 325mg (65mg iron) give one tablet oral twice daily for electrolyte imbalance supplement. 4. Clinical records for P#8 were reviewed for certification date 12/8/21 to 3/7/22. Per the patient's plan of care, the patient was admitted to hospice services on 9/9/21, with a primary diagnosis of coronary heart disease, epilepsy, myocardial infarction, malignant melanoma of skin, metabolic encephalopathy, gastrointestinal hemorrhage, gastroesophageal reflux disease (GERD), ulcerative, acute respiratory failure and depression. The record showed the agency was not providing coverage for payment for the following medications used to manage the co morbidities: -Lexapro 10mg give one tablet oral for depression. -Pepcid 20mg give one tablet oral at bedtime for treatment of gastroesophageal reflux disease. During interview at the agency's office on 3/17/22, at 9:30 a.m., the Administrator and Vice President of Clinical Operation both stated, they were unaware that it was a requirement to pay for medications related to listed co morbidities on the patients' plan of care.