Every finding on record at Athena Hospice, Inc.

Upon observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient's Rights and Responsibilities in a language and manner that the patient understands. Patient#2: The patient's primary language is Spanish. During home visit is was noted there is no evidence of patient rights and responsibilities being provided in writing in Spanish. Corrected on site. Patient#3: The patient's primary language is Armenian. During home visit is was noted there is no evidence of patient rights and responsibilities being provided in writing in Armenian. Corrected on site.

Upon patient record review, 3 of 14 (Patient #1,#8,#10) 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: The record indicates aspiration precautions are indicated on aide plan of care and are ordered on physician order dated 5/20/24. However, there is no evidence of goals or interventions related to aspiration precaution on plan of care. Corrected on site. Patient#8: The record indicates bleeding precautions were ordered by physician on 5/25/25. The is no evidence of goals or interventions related to this on plan of care. Corrected on site. Patient#10: The record indicates physician ordered oxygen safety precautions and aspiration precautions on 4/18/25. However, there is no evidence of goal or interventions on plan of care related to these orders. Corrected on site.

Upon patient record review, 1 of 14 (Patient #1) 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 aide plan of care indicates patient requires use of mechanical lift. During home visit it was noted that patient uses hospital bed. There is no evidence of these items on plan of care. Corrected on site.

Upon patient record review 1 of 14 (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: The record indicates that on LVN visit 5/27/25 the LVN documented patient reported having a pounding headache and having pain to lower extremities. There is no evidence or documentation that there were any interventions or follow up regarding these complaints.

Upon patient record review, 1 of 14 (Patient #1) 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: The record indicates the patient is prescribed cardiac diabetic diet. The aide plan of care indicates "as tolerated". There is no evidence of a specified diet on aide plan of care. Corrected on site.

Upon patient record review, 2 of 14 (Patient #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#5: The record indicates LVN documented on 5/4/25 visit that patient complained of generalized body pain in the narrative. However, in pain section of the same visit it is documented that patient had no pain and gives a 0 for numerical pain rating. Patient#7: The record indicates LVN documented on 6/2/25 that patient awake and alert but complains of generalized body pain. However, in pain section of same visit it is documented that patient has no pain and gives a numerical rating of 0.

Upon patient record review, 1 of 5 (Patient #3) 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. Patient 3: The medication profile contains escitalopram 20mg 1 tab at bedtime. Upon home visit finding the prescription bottle is labeled escitalopram 10mg 1 tab at bedtime. Corrected on site.

Upon patient record review, 1 of 5 (Patient #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 3: The POC contains escitalopram 20mg 1 tab at bedtime. Upon home visit finding the prescription bottle is labeled escitalopram 10mg 1 tab at bedtime. Corrected on site.

Upon patient record review, 1 of 5 (Patient #1) 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: Upon home visit finding, pt has a hospital bed. There is no evidence of an order for a hospital bed on the POC. Corrected on site.