Every finding on record at Ascension Hospice, LLC

Upon patient record review, 3 of 14 (Patient #2, 6, 7) 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: Patient had indwelling Foley with ongoing UTI requiring treatment . There are no related problems, goals, interventions for catheter or infection. Patient #6: Patient has DM and protein calorie malnutrition with sliding scale insulin with Metformin and Megace prescribed. There are no related problems, goals, interventions. Patient #7: Patient admitted with Foley catheter, but no related problems, goals, interventions.

Upon patient record review, 7 of 14 (Patient #3, 4, 6, 7, 8, 9, 10) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #3, 4, 6, 7, 8, 9: MSW and SC 1/monthly and 3 prn every 30 days prn visits for acute and follow up needs. Patient #10: SN frequency 1 visit every 90 days, 3 prn visits every 30 days - prn visits for acute and follow up needs. RN is 1x/week and 6 prn every 30 days. MSW and SC 1x/monthly and 3 prn every 30 days prn visits for acute and follow up needs.

Upon patient record review, 3 of 14 (Patient #2, 7, 12) 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: Patient admitted 1/23/26 with Foley catheter in place. 1/23/26 order says may add administration of Foley catheter care; change 1x/month and prn. The order does not state the reason for the PRN catheter change. In addition, there was no reference to catheter size or balloon size. Patient #7: 2/10/26 order, May add administration of Foley catheter care; change 1x/month and prn. The order does not state the reason for the PRN catheter change. In addition, there was no reference to catheter size or balloon size. Patient #12: 1/6/16 order, May add administration of Foley catheter care; change 1x/month and prn. The order does not state the reason for the PRN catheter change. In addition, there was no reference to catheter size or balloon size.

Upon patient record review, 3 of 14 (Patient #5, 6, 7) 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 #5: Order on 3/27/26 for Doxycycline 100 mg twice/day wound LLL. No update to problems, goals, interventions. Patient #6: 4/11/26 PRN visit related to red, hot LLE. Doxycycline ordered. No update to problems, goals, interventions. Patient #7: 4/6/26 order for Depakote for seizure activity. No update to problems, goals, interventions. Patient experienced fall 3/2/26. RN made visit. Patient had fallen and hit head. Lacerations visualized. Wife had applied gauze and Bandaid dry and intact, requested no change dressing at this time. Wound supplies left on site. Eliquis discontinued. No update to problems, goals, interventions related to fall or related wound care.

Upon client record review, 2 of 14 (Patient #2, 5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: The 2/3/26 SN visit note stated Foley catheter removed 2/3/26. No documented evidence of a physician order for removal at that time. Patient #5: SN visit notes on 3/27, 3/31 and 4/7/26 documented providing wound care to LLE. No documented evidence of orders for wound care provided.

Upon patient record review, 5 of 14 (Patient #3, 7, 8, 9, 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 #3: Patient admitted with ESRD and cessation of dialysis. Patient has dialysis catheter right upper chest and right sided nephrostomy (inadvertently documented as urostomy). Neither are identified on the aide care plan for catheter safety. Patient #7: Patient had Foley catheter and documented seizures with no reference on the aide care plan. Patient #8, 9: Patient has Oxygen 2-4 LPM via NC continuously as needed ordered. No oxygen flow rate or precautions included on the aide care plan. Patient #12: Patient admitted with Foley catheter with no reference on the aide care plan

Upon patient client record review, 4 of 14 (Patient #2, 3, 5, 7) 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 #2: There was a 2/3/26 SN visit to remove Foley catheter, but no reference to deflation of balloon/amount. Record did not contain size/balloon of existing cath. This RN removed the indwelling catheter, catheter was intact. Patient tolerated w/o pain, discomfort, small amount yellow urine <100 ml in bag. Patient #3: Initial comprehensive assessment, SN documented presence of urostomy, but upon visit and interview with staff, confirmed the patient actually has nephrostomy tube. Patient #5: Visit 4/7/26: This RN provides wound care - wound to LLE is mostly healed, no pain or redness at wound site, bandage encouraged to protect scab from accidental removal by dog claws. 3/31/26: This RN provides wound care to anterior LLE r/t skin tear; wound appears to be healing with increased granulation tissue and decreased pain and redness at wound site. Patient reports changing bandage daily, decreased pain and discomfort. This RN cleansed with wound cleanser, pat dry with gauze, applied ointment (not specified) and foam dressing. 3/27/26 This RN cleaned wound with wound spray, applied ointment (not specified), covered with foam dressing. Patient #7: Foley was documented at admission related to status post cancer prostate. No further documentation in the record of whether patient has a foley catheter.

Upon client record review, 1 of 14 (Patient #3) 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 #3: SNF resident admitted with dialysis catheter and nephrostomy (inadvertently documented as urostomy), according to comprehensive assessment. However, there are no related problems, goals, interventions on the plan of care. Patient has IDDM and complaints of intermittent pruritus with no related problems, goals, interventions. In addition, visits on 4/6/26 and 4/12/26 the SN documented multiple areas of skin breakdown both breasts, with no update to problems, goals and interventions.

Upon client record review, 1 of 14 (Patient #3) 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 #3: SNF resident admitted with dialysis catheter and nephrostomy (inadvertently documented as urostomy), according to comprehensive assessment. Upon interview, ADON states that facility manages the catheter and urostomy, although this is not reflected in care plan on who is providing the catheter care.

Upon patient record review, 1 of 14 (Patient #9) and as observed during home visit, patient's medication records was not completed and current. SNF Medication records included that patient has Morphine Sulfate Oral Solution 20MG/5ML (0.25ml and 0.50ml by mouth every 1 hour PRN for pain or shortness of breath, and Atorvastatin calcium 10MG 1 tablet by mouth at bedtime which were not included in the Hospice Medication profile.

Upon client record review, 1 of 14 (Patient #12) the discharge summary did not include a summary of the patient's stay, treatments, symptoms and pain management, current plan of care, and latest physician orders and other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility.

Upon policy and procedure review, the agency Covid 19 vaccination policy did not include any evidence the Hospice has developed written policies procedure that has a Contingency plan for personnel who are not fully vaccinated for COVID-19.