Every finding on record at Ark Hospice, LLC

Upon patient record review, 19 of 19 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18, and 19) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient #1-19: There was no evidence in the record of documentation regarding imminence of death.

Upon patient record review, 3 of 19 (Patient # 1, 3 and 4) 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: Patient 1: Upon home visit, agency medication list contains multiple medications with oral route of administration and patient has a PEG tube in place and all medications are being administered enterally via PEG tube at facility. Patient is receiving PEG tube feedings of Osmolyte 20h/day via PEG tube with no evidence on the medication profile. Corrected on site with updated profile. Patient 3: Upon home visit, Tramadol is noted on the ALF medication profile and agency medication profile does not list this medication. Corrected on site with updated profile. Patient 4: Upon home visit, agency medication profile contains incomplete orders for nasal spray without directions for use and Miralax 17 grams dose 1 powder without directions for diluent. Corrected on site with updated profile.

Upon patient record review, 1 of 19 (Patient #4) 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 4: The POC contains an order for Eliquis 5mg BID with no evidence of risk for bleeding on POC 7/3/25.

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 medications and treatments. Patient 3: Upon home visit, the updated POC does not contain an order for Tramadol which is noted on the patient's medication list at her place of residence. Corrected on site with agency collaboration with ALF and obtained new physician order and POC updated. Patient 4: The initial POC on 10/31/24 and updated POC 7/3/25 contains an incomplete order for nasal spray without directions for use and Miralax 17 gm dose powder without directions for diluent. Corrected on site with updates to current POC and orders received for complete orders.

Upon patient record review, 2 of 19 (Patient #6, 9) 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 6: Updated POC 6/21/25 contains orders for nebulizers with no nebulizer equipment listed on updated POC at recertification. Corrected on site with updated POC. Patient 9: Initial POC 5/10/25 contains orders for Nebulized medications including Stiolto Respimat and albuterol noted on medication profile without equipment listed as ordered on the POC. Corrected on site with updated POC.

Upon patient record review, 1 of 19 (Patient #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 6: Updated POC 6/21/25 contains an order for Xarelto 20 mg with no risk of bleeding precautions. Corrected on site with updated POC.

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. No evidence that the agency utilized volunteers for at least 5% of the total patient care hours in 2024. The total usage of volunteers for 2024 was 2.54%

Upon patient record review, 2 of 19 (Patient #1, 8) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 1: Initial POC 5/10/24 does not contain evidence of a PEG tube with feeding Osmolyte 20 hour daily and PEG tube maintenance, care and equipment details are not included in the initial POC. POC contains "SN to provide orders per wound care orders" without wound care details. Corrected on site by obtaining more detailed orders and updates to the POC. Patient 8: The initial POC 6/25/25 mentions NG, Trach, Peg tube with no specific order details regarding assessment, treatment orders, dressing, care of NG, PEG or trach maintenance. No supplies or equipment orders noted on POC.

Upon patient record review, 2 of 19 (Patient #1, 8) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 1: POC contains "SN to provide orders per wound care orders" without wound care details on who will be providing the wound care either by SNF or agency SN. Corrected on site by obtaining more detailed orders and updates to the POC. Patient 8: The initial POC 6/25/25 mentions NG, Trach, Peg tube with no details on who will be providing this care at SNF.

Upon patient record review, 3 of 5 records (Patient #2, #3, #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 2: Medication profile dated 6/9/2022 includes Oxygen 2L inh. continuous for breathing difficulty/copd. There is no evidence of a clear route. Corrected on site. Patient 3: Medication profile dated 7/7/2022 for Ammonium Lactate 12% topical 2x daily to affected area. There was no evidence of an affected area. Corrected on site. Patient 5: Medication profile dated 9/4/2022 includes Oxygen 4L inhaled cont. all the time medical gas for COPD. There was no evidence of a route for O2 on the medication profile.

Upon patient record review, 2 of 5 records (Patient #2, #3) 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 2: Order dated 6/9/2022 includes Oxygen 2L inh. continuous. There was no evidence of a route or reason for the O2. Plan of care dated at SOC includes O2 continuous via n/c, there was no evidence of a reason given. Corrected on site. Patient 3: Plan of care dated at SOC included order for Ammonium Lactate 12% topical 2x daily to affected area. There was no evidence of an affected area. Corrected on site.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 1: RN reached into clean bag while providing patient care without removing dirty gloves or cleansing hands to retrieve a pulse oximeter and antiseptic wipes.

Upon patient record review, 1 of 5 records (Patient #4) 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 4: Initial orders at SOC included an entry for SN visits that has been written over and is not legible. Corrected on site.

Upon observation, there was no evidence of a CLIA certificate for the hospice performing waived testing. DCPS/RN carries own glucometer for use, no evidence of a CLIA Waiver. Agency applied while surveyor was on-site, and have the process started to obtain.