Every finding on record at Adventa Hospice, LLC

Upon patient record review, 1 of 27 (Patient #5) 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 #5: Upon Surveyor-attended home visit with the Hospice SW on 06/02/26, upon arrival at the patient's home the daughter was observed administering NTG sublingual to the patient/her father, who was experiencing chest pain. The Hospice Nurse had been notified and was on her way. Meanwhile, the Surveyor noted that NTG was not on this patient's Medication Profile.

Upon patient record review, 4 of 27 (Patients #4, 5, 10, and 14) did not contain evidence that the Hospice had 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 #4: The RN SOC assessment noted that the patient had a pacemaker. This pertinent health information was not included on the current POC. Patient #5: Upon Surveyor-attended home visit with the Hospice SW on 06/02/26, the daughter was observed administering NTG sublingual to the patient/her father, who was experiencing chest pain. The Hospice Nurse had been notified and was on her way. Meanwhile, the Surveyor noted that NTG was not on this patient's Hospice Plan of Care. Patient #10: The RN SOC assessment noted that the patient had an implanted vascular access port. This pertinent health information was not included on the current POC. Upon interview the RN Case Manager reported that the port has remain un-used. Patient #14: The RN SOC assessment noted that the patient had a pacemaker. This pertinent health information was not included on the current POC.

Upon patient record review, 2 of 27 (Patients #2 and 4) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including the following: A detailed statement of both the scope and frequency of the services necessary to meet the specific patient and family needs: Patient #2: The Hospice POC dated 05/04/26 included, "Volunteer visit frequency effective 05/04/26, four p.r.n. visits for companionship. Volunteer services will be available to patient/caregiver as needed for companionship and socialization." The IDG POC dated 05/28/26 included, "Patient/caregiver response to Volunteer services - Yes." (No Volunteer visits had been made since 03/05/26). A Volunteer visit frequency must include a baseline visit frequency. Patient #4: The Hospice POC dated 04/20/26 to 06/18/26 included, "Volunteer visit frequency effective 04/20/26, four p.r.n. for companionship. Volunteer services will be available to patient/caregiver as needed for companionship; followed by a listing of 13 potential Volunteer interventions." A Volunteer visit frequency must include a baseline visit frequency, to which a p.r.n. frequency may be added to.

Upon patient record review 3 of 27 (Patients #4, 7 and 13) did not contain evidence that a Registered Nurse had made an on-site visit to these patients' homes 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 #4: An Aide supervisory visit was made on 05/05/2026, and then not again until 05/20/2026. Patient #7: An Aide supervisory visit was made on 05/11/2026, and then not again until 05/27/2026. Patient #13: An Aide supervisory visit was made on 04/28/2026, and then not again until 05/14/2026.

Upon observation, and interview with the Regional Clinical Nurse, there was not evidence that the Hospice's Annual Report documented 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. The Hospice's calendar year 2025 Volunteer Report reflected 2.27% rate.

Upon patient record review, 5 of 27 (Patient #3,#8,#9,#10,#11) 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:The medication profile included oxygen to be delivered at 2 liters per minute. The route for oxygen administration was not included. Corrected on site. Patient 8: The medication profile had a 6/3/23 entry of MiraLAX powder 17 gm daily as needed. There was no evidence in the instructions of the type and amount of diluent needed for administration. Corrected on site. Patient 9: The medication profile had a 6/3/23 entry of MiraLAX powder 17 gm daily as needed. There was no evidence in the instructions of the type and amount of diluent needed for administration. The medication profile included oxygen to be delivered at 2 liters per minute. The route for oxygen administration was not included. Corrected on site. Patient 10:The medication profile 4/19/23 included entry for oxygen at 2-5 liters per minute. The route for delivery and instructions for titration of oxygen were not included. Corrected on site. Patient 11: The medication profile included MiraLAX powder 17 gm daily as needed. There was no evidence in the instructions of the type and amount of diluent needed for administration. The medication profile included oxygen to be delivered at 2 liters per minute. The route for oxygen administration was not included. Corrected on site.

Upon patient record review, 1 of 27 (Patient #12) 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 12:The patient was admitted to hospice services on 05/01/23. The initial Bereavement Risk Assessment was completed on 6/21/23.

Upon patient record review, 3 of 27 (Patient #8,#15.#19) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 8:The patients medical record contains nursing documentation on 5/3/23 of new stage II pressure ulcer to sacrum. Wound assessments with measurements completed 5/3/23,5/12/23 and 5/22/23. No evidence of wound measurements documented in record from 5/22/23 to 6/20/23. Patient 15:The patients medical record contains nursing documentation upon admission of a stage II pressure ulcer to coccyx assessed. No evidence of wound measurements documented in record since admission 4/11/23. Patient 19:The patients medical record contains nursing documentation upon admission of a stage II pressure ulcer to coccyx assessed. No evidence of wound measurements documented in record since 6/5/23.

Upon patient record review, 2 of 27 (Patient #11,#14) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient 11:The patients medication profile included Seroquel, Hyoscyamine, Ativan, morphine, Levaquin, tramadol. There is no evidence that education on purpose, directions and side effects were provided to the patient and caregiver. Corrected on site Patient 14:The patients medication profile included Bumetanide and Senna. There is no evidence that education on purpose, directions and side effects were provided to the patient and caregiver. Corrected on sire

Upon patient record review, 6 of 27 (Patient #2,#3,#4.#6,#7,#16) 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 2:The patients medical record contained nursing documentation upon admission of foley catheter in place and oxygen in use. There was no evidence of care plan problems with goals and interventions related to genitourinary issues and no problems with goals and interventions for oxygen therapy. Patient 3:The patients medical record contained nursing documentation upon admission of oxygen in use by patient. There was no evidence of care plan problems with goals and interventions related to oxygen therapy. Corrected on site. Patient 4:The patients medical record contained nursing documentation upon admission of primary diagnosis of hypertensive kidney disease and comorbidity of stage 4 pulmonary fibrosis with nebulization treatments and oxygen in use. There was no evidence of care plan problems with goals and interventions related genitourinary issues and no care plan problems with goals and interventions related to respiratory issues. Corrected on site. Patient 6:The patients medical record contained nursing documentation upon admission of primary diagnosis of cirrhosis of liver with comorbidity of diabetes mellitus requiring insulin administration with recurring wound and nutritional issues. There was no evidence of care plan problems with goals and interventions related to liver disease and no evidence of care plan problems with interventions and goals to manage diabetes mellitus. Corrected on site. Patient 7:The patients medical record contained nursing documentation upon admission of issues with dysphagia and aspiration risk. There was no evidence of care plan problems with goals and interventions related to dysphagia. Corrected on site Patient 16:The patients medical record contained nursing documentation upon admission of Eliquis and aspirin for anticoagulation. There was no evidence of care plan problems with goals and interventions related to anticoagulation. Corrected on site.

Upon patient record review, 6 of 27 (Patient #1,#9,#10,#11,#12,#13) 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 1:The patients medical record contained nursing documentation on 5/5/23 and 5/11/23 that caregiver stated that patient's use of MiraLAX and milk of magnesia for relief of constipation has been effective. There is no evidence that MiraLAX and milk of magnesia are part of the plan of care. Corrected on Site Patient 9: The plan of care included MiraLAX powder 17 grams daily as needed. There is no evidence of a diluent. The plan of care included oxygen at 2 liters per minute. There is no evidence that a route for oxygen delivery. Corrected on site. Patient 10:The plan of care included entry for oxygen at liters 2-5 liters per minute. There was no evidence of the route for delivery and instructions for titration of oxygen. Corrected on site. Patient 11:The patients medical record contained nursing documentation on 6/14/23 that patient had begun to use Robitussin expectorant. There is no evidence of an order for Robitussin expectorant. The plan of care included MiraLAX powder 17 grams daily as needed. There is no evidence of a diluent. The plan of care included oxygen to be delivered at 2 liters per minute. There is no evidence of a route for oxygen administration. Corrected on site. Patient 12:The patients medical record contained nursing documentation on 6/20/23 of wound to leg. There is no evidence in the plan of care of who is to provide wound care. The patients medical record includes nursing documentation on 5/16 /23 and 5/19/23 of patient receiving oxygen at 3 liters per minute via nasal cannula. There is no evidence that oxygen is included in the plan of care. Corrected on site. Patient 13:The patients medical record contained nursing documentation on 5/20/23 of placement of foley catheter. There is no evidence of the catheter size or balloon inflation in the plan of care. Corrected on site.

Upon patient record review, 11 of 27 (Patient #1,#2,#3,#5,#6,#7,#8,#9,#11,#12,#13) 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 1:The patients medical record contains documentation upon admission that patient utilized a wheelchair for mobility. There is no evidence that a wheelchair is present on the plan of care. Corrected on site. Patient 2:The patients medical record contains documentation upon admission that a wheelchair and overbed table were in use. There is no evidence that a wheelchair and overbed table are present on the plan of care. Corrected on site. Patient 3:The patients medical record contains documentation upon admission that patient utilized a wheelchair for mobility. There is no evidence that a wheelchair is present on the plan of care. Corrected on site. Patient 5:The patients medical record contains documentation upon admission that patient utilized a wheelchair for mobility. There is no evidence that a wheelchair is present on the plan of care. Corrected on site. Patient 6:The patients medical record contains documentation on 04/18/23 that a wheelchair, grab bars and hospital bed were in use by patient. There is no evidence that a wheelchair, grab bars and hospital bed are present on the plan of care. Corrected on site. Patient 7: The patients medical record contains documentation upon admission that a wheelchair, walker and shower chair were in use by patient. There is no evidence that a wheelchair, walker and shower chair are present on the plan of care. Corrected on site. Patient 8: The patients medical record contains documentation on 04/16/23 that patient utilized a wheelchair for mobility. There is no evidence that a wheelchair is present on the plan of care. Corrected on site. Patient 9: The patients medical record contains documentation upon admission that a wheelchair, hospital bed, oxygen equipment/supplies and nebulization equipment/supplies were in use by patient. There is no evidence that a wheelchair, hospital bed, oxygen equipment/supplies and nebulization equipment/supplies are present on the plan of care. Corrected on site. Patient 11:The patients medical record contains documentation upon admission that a wheelchair and hospital bed were in use by patient. There is no evidence that wheelchair and hospital bed are present on the plan of care. Corrected on site. Patient 12:The patients medical record contains documentation upon admission that oxygen equipment/supplies and were in use by patient. There is no evidence that oxygen equipment/supplies are present on the plan of care. Corrected on site. Patient 13:The patients medical record contains documentation upon admission that a walker, hospital bed, overbed table, oxygen equipment/supplies and nebulization equipment/supplies were in use by patient. There is no evidence that a walker, hospital bed, overbed table, oxygen equipment/supplies and nebulization equipment/supplies are present on the plan of care. Corrected on site.

Upon patient record review, 2 of 27 (Patient #2,#12) 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:The aide plan of care does not include evidence of a frequency for completion of any of the tasks assigned to the aide. Corrected on site. Patient 12:The aide plan of care includes the tasks of bed bath and shower assigned to the aide to be completed every visit. Corrected on site.

Upon patient record review 1 of 27 (Patient #15) 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 15:The patients medical record contains documentation that the patient's foley catheter was removed on 4/18/23. The aide visits on 4/20/23 ,4/24/23, 4/27/23, 5/4/23, 5/11/23 and 5/18/23 included documentation that the tasks of catheter care and empty drainage bag been completed.

Upon patient record review, 1 of 27 (Patient #17) 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 17:The patients medical record upon admission contains documentation of electric and nonelectric bed, rails, scooter, long handled shower and pain pump. There is no evidence that an electric and nonelectric bed, rails, scooter, long handled shower and pain pump were in use by the patient and part of the plan of care. Agency confirmed that patient was not utilizing these items. Corrected on site.