Every finding on record at Authoracare Collective

Upon patient record review, 1 of 33 (Patient #8) 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 #8 - Medication profile contains Diazepam 5mg/ml give 2.5 mg (0.5 ml) every 6 hours injection - did not specify if IM, SQ or IV.

Upon patient record review, 2 of 33 (Patient #13, 29) 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 #13 - Patient has wound to L heel and L ankle - no measurements of wound effective 08/21/25 x 3 weeks. Patient #29 - Patient has wound to sacrum - wound measured and assessed on 08/23/25 then no documentation as of 09/09/25 of wound assessment or measurements.

Upon patient record review, 4 of 33 (Patient #11, 12, 29, 30) 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 #11 - Aide 3 x a week and does not identify for personal care. Patient #12 - Aide 2 x a week and does not identify for personal care. Patient #29 - Aide 2 x a week and does not identify for personal care. Patient #30 - Aide 2 x a week and does not identify for personal care.

Upon patient record review, 3 of 33 (Patient #8, 11, 18, 29) 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 #8 - SN visit note on 09/07/25 "foley catheter with 50cc output" but no related orders for the care and management of the Foley catheter. Patient #11 - Order to change indwelling 14F or 16F catheter per agency protocol. Patient #18 - SN visit note 08/18/25 patient is on O2 at 2.5 L/M there is no order in the chart for this. Patient #29- Wound care to sacrum did not have modifier for PRN dressing changes. Patient has Foley Catheter but no related orders for the care and management of the Foley catheter.

Upon client record review, 3 of 33 (Patient #)14, 17, 26 did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #14 - SN visit 07/03/25 "clean wound by soaking gauze with wound cleanser and leaving in place 5-10 minutes, place calcium alginate cut to size, cover and secure" there is no order in the chart for this. Patient #17 - SN visit 08/30/25 "instructed to give Miralax when patient is constipated" there is no order in the chart for this. Patient #26 - SN visit note "patient has a peripheral IV in R forearm that flushes well" no order in chart for peripheral IV or flushes.

Upon patient record review, 4 of 33 (Patient #11, 16, 25, 26) 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 #11 - Aide care plan did not include oxygen safety or Foley Catheter care. Patient #16 - Aide care plan tasks contain Shower every visit, bed bath every visit and partial sponge bath every visit. No documentation patient is functionally or cognitively able to make decision. Patient #25 - Aide care plan does not include oxygen safety. Patient #26 - Aide care plan includes task - perineal care as needed, shampoo as needed and change bed linen as needed. Prepare snacks and offer fluids but patient is NPO.

Upon patient record review 2 of 33 (Patient #12, 16) 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 #12 - Aide care plan task: ear care and nail care to be provided 1 x week. Aide provided 2 x week, week of 07/08/25 and 08/12/25. Patient #16 - Aide care plan task: shampoo every visit - did not provide shampoo 08/12/25, 08/19/25 or 08/26/25 and did not document reason for omitting shampoo.

Upon patient record review 2 of 33 (Patient #12, 21) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home 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 #12 - RN completed aide supervisory visit on 07/15/25 then again on 08/05/25 (20 days between Aide Supervisory visits) Patient #21 - RN completed aide supervisory visit on 08/21/25 - no other Aide Supervisory visits as of 09/08/25.

Upon patient client record review, 3 of 33 (Patient #18, 29, 31) 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 #18 - RN completed Aide Supervisory visit on 08/04/25 and 08/18/25 but patient is not receiving aide visits. Patient #29 - RN documented on 09/09/25 patient on oxygen 4L/M in narrative of note but section where vital signs are documented, RN documented oxygen at 2L/M. Patient #31 - RN documented patient has Foley Catheter but patient has condom catheter.

Upon client record review, 1 of 33 (Patient #20) 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 #20 - SNF resident admitted 07/30/25 with wound care to sacral wound. There is no documented evidence of which provider is to provide wound care to the patient.

Upon observation, there was no evidence the inpatient facility has adequate supply of hot water at all times and include plumbing fixtures with control valves that automatically regulate the temperature of hot water used by patients per facility policy, "Utilities Management Plan IPU-M90." Location A: Patient room water temperatures were noted > than the range of 110-116. 1/3/25 119 F, 1/10/25, 118 F, 1/17/25 117 F, 1/24/25 119 F, 1/30/25 118 F, 2/6/25 119 F, 2/21/25 118 F and 3/7/25 118 F. All rooms and the break room are checked weekly per the temperature log. The log does not designate which rooms were high, facility noting highest temperature checked for all rooms. Facility did not note if and when the temperature of the water was corrected.

Based on agency policy, observation, clinical record review, and staff interviews, the agency failed to include an accurate list of medications for 1 of 2 patients with an observation visit conducted. (patient #1)Findings included: --- A policy, Medication: Management & Administration (revised 02/20/2025) received on 09/02/2025 at 4:49 PM from the Quality and Compliance Coordinator stated, “A registered nurse maintains a current medication profile and reviews all patient medications… A medication profile includes but is not limited to 1) all current medications…”Patient #1 was admitted on 04/09/2024 with a diagnosis of malignant neoplasm (cancer) of the esophagus. The plan of care for 08/02/2025-09/30/2025 included orders for skilled nurse visits 1 time a week for 9 weeks with 8 PRN (as needed). During a home visit conducted on 09/02/2025 at approximate 11:45 AM with registered nurse (RN) #7 a comprehensive medication review revealed the following:1. The patient had been prescribed Lidocaine 4% topical (for pain) patches for pain apply 1 time daily and were not included in the plan of care.2. The plan of care included Metoprolol Succinate ER 50mg (treats blood pressure) 0.5 tablet daily. The prescription bottle was dated 08/05/2025, the patient stated that he had taken 1 tablet daily “for a long time.”3. The plan of care included an order for Pantoprazole 40mg (reduces acid) 1 tablet daily. The patient stated that they do not remember ever taking that.4. The patient reported taking acetaminophen (treats pain/fever) 500mg as needed for pain for as long as he can remember. Acetaminophen was not included in the plan of care.An interview conducted on 09/02/2025 at approximately 4:05 PM with registered nurse #7 revealed that a comprehensive medication review is conducted at every nurse visit, medications should be added, discontinued, or changed as ordered by a physician. During an interview conducted on 09/02/2025 at approximately 4:45 PM the senior director of home hospice stated, "We would expect [documentation software name] to be up to date."

Based on agency policy, observation, and staff interviews, the agency failed to perform hand hygiene after handing personal items and failed to sanitize reusable equipment before placing it in the clinical bag for 1 of 2 patients with observations conducted. (patient #1)Findings included: --- A policy, Infection Control-Standard Precautions (revised 04/17/2025) received on 09/03/2025 at4:49 PM from the Quality and Compliance Control Coordinator stated, “Perform hand hygiene: After contact with patient’s intact skin (when taking a blood pressure or pulse) … After contact with inanimate objects in the immediate vicinity of the patient… Non-critical objects such as stethoscopes; BP [blood pressure] cuffs; pulse ox; etc... Should be disinfected after patient care…” Patient #1 was admitted on 04/09/2024 with a diagnosis of malignant neoplasm (cancer) of the esophagus. The plan of care for 08/02/2025-09/30/2025 included orders for skilled nurse visits 1 time a week for 9 weeks with 8 PRN (as needed). During a home visit conducted on 09/02/2025 at approximately 11:45 AM registered nurse (RN) #7 failed to perform hand hygiene after handling the patient's medication bottles then removing vital sign equipment from the clinical bag and failed to sanitize the blood pressure cuff and pulse oximeter before returning it to the clinical bag.During an interview conducted on 09/02/2025 at 4:04 PM RN #7 stated, “I normally wipe it [equipment and bag] down when I get back to the car. I normally perform hand hygiene before entering the bag.”During an interview conducted on 09/02/2025 at approximately 4:45 PM the senior director of home hospice stated the expectation is, “To clean her equipment [after patient use] and [before entering the clinical bag] wash hands or use gel [hand sanitizer].”

Based on policy review, clinical record review, and staff interview, the agency failed to obtain urinalysis according to physician orders for 1 of 1 patient with urinalysis ordered (#2). Findings included: --- A policy, ";Coordination of Services" (dated 12/17/21), was provided by the Director of Compliance on 4/26/23 at approximately 12:00 p.m. The policy stated, ";The RN Case Manager coordinates the patients plan of care and facilitates the ongoing sharing of information..." A policy, ";Hospice Care for Nursing Facility Residents—Hospice Plan of Care" (dated 1/20/22) was provided by the Director of Compliance on 4/26/23 at approximately 12:00 p.m. The policy stated, ";The RN Case Manager assigned to the facility patient is responsible for coordinating and implementing the patients plan of care...The plan of care for the facility patient identifies the care and services that are needed..." Patient #2 was admitted to the agency on 8/24/22 with hypertensive heart and chronic kidney disease with heart failure. The patient resided in a long-term care facility. The Plan of Care for 11/22/22-2/19/23 included orders for skilled nursing [SN] visits one to three times per week for 13 weeks with eight as needed (prn) visits for symptom management. A clinical note from 12/15/22 at 7:38 p.m. stated, ";Arrived to [sic] patient home...new order for UA C&S Stat [urinalysis with culture and sensitivity as soon as possible]. On 12/16/23, a clinical note (signed at 12:42 p.m.) stated, ";TC [telephone call] from pts [patients] son he was expecting a nurse visit 1st thing this morning to collect a urine [sic] from the pt due to on call visit last night." The interdisciplinary team [IDT] meeting note for 12/21/22 stated, ";UA gathered [sic] on pt, SN to follow up with results." A lab document, provided by the agency, confirmed a urinalysis was collected on 12/16/23 at 1:30 p.m. The lab document revealed the urine specimen did not include a name or identification. A clinical note on 12/29/22 revealed at 12:21 p.m., the long-term care facility called the hospice agency and stated that the patient had a urinary tract infection (UTI) according to the urinalysis. On 12/29/22 (time unclear, but note completed at 11:22 p.m.), a clinical note stated that the nurse spoke with the patients son regarding the collection date of the urinalysis. The nurse reported to the son the collection date was ";11/22 [sic]" and the urinalysis resulted on ";11/23 [sic]." An interview was conducted with the Vice President of Nursing Services on 4/26/23 at 4:45 p.m. The interview revealed the UA collected was on 12/16/22. There was no label on the specimen. The urine was collected again on 12/22/23. An interview with the manager on 4/26/23 at 4:22 p.m. stated that the urine should have been collected the date the order was obtained.

Based on clinical record review, caregiver interview and staff interview the agency failed to allow the patient representative be present during the initial assessment for 1 of 3 patients [#1]. The findings included: --- Patient # 1 had a Start of Care date of 9/2/22 and a terminal diagnosis of COVID Pneumonia. Patient # 1 was admitted to ________ [name of inpatient unit] on 9/2/22. Prior to the admission to hospice, Patient # 1 had been inpatient at _______ [name of hospital] from 8/16/22 until 9/2/22. Review of the hospital records revealed the patients daughter was the surrogate decision maker for the patient. The daughter arrived at the hospice inpatient unit with patient # 1 per documentation by RN # 1. Review of the clinical record revealed the patients daughter signed all hospice consents. Review of Chaplain # 3s initial assessment dated 9/2/22 revealed the following information, ";...Met with _______ [daughter] and ______ [son] as pt [patient] arrived by EMS [emergency medical services] to room, and daughter very anxious and frantic to be with pt at all times...now angry that she is not allowed in room as pt is assessed and settled into bed..." During an interview with the daughter on 10/31/22 at approximately 1:15 pm, the daughter stated that she was not allowed in the room with the patient while the staff ";got the patient settled in". The daughter stated, ";I tried to go to Mama. The chaplain stopped me and told me I would need to wait in the family room. I was in the family room with the chaplain for 45 minutes." During an interview with the inpatient manager [RN # 2] on 10/31/22 at approximately 2:30 pm, the manager confirmed the daughter was asked to wait outside the room. ";I dont think it was 45 minutes, but she was asked to wait in the family room with the chaplain. We have had a staff meeting since that incident and I told the staff to never refuse to let a family member stay with a patient at any time."

Based on clinical record review and staff interviews the agency failed to provide pain management/symptom control for 1 of 1 patient with severe dyspnea [shortness of breath] # 1. The findings included: --- Patient # 1 had a Start of Care date of 9/2/22 and a terminal diagnosis of COVID Pneumonia. Patient # 1 was admitted to _______ [name of hospice inpatient unit] on 9/2/22. Review of the Plan of care for the certification period 9/2/22 to 11/30/22 revealed orders for ";LORazepam [sic] by mouth tablet 1 mg-1 tablet as needed PO [by mouth] every 4 hours PRN [as needed] anxiety/restlessness/nausea...Morphine Sulfate by mouth solution 20 mg/ml 5 mg as needed PO every 4 hours PRN moderate pain/dyspnea DOSE = 0.25 ml...Morphine Sulfate by mouth solution 20 mg/ml 10 mg as needed PO every 2 hours PRN severe pain/dyspnea DOSE 0.50 ml..." Review of the clinical record revealed the following documentation by RN # 1, ";9/2/22 at 1625 [4:25 pm] Pt. [patient] arrived on unit...1700 [5 pm] ...severe dyspnea with any movement. Patient had to be in high fowlers position [standard patient position in which the patient is seated in a semi-sitting position and may have knees either bent or straight. It is an intervention used to promote oxygenation via maximum chest expansion and is implemented during events of respiratory distress] ..." Review of the medication administration record revealed the patient did not receive the first dose of Morphine until 6:45 pm when she received 10 mg for severe pain/dyspnea. Patient # 1 did not receive the first dose of LORazepam [sic] until 9:20 pm. Further review of the clinical record revealed RN # 1 documented the following information on 9/2/22 at 1955 [7:55 pm], ";Pt having periods of waking up and with anxiety. Brow smoothing out and pt opening and closing eyes. Decision made to wait on giving additional medication..." Patient # 1 did not receive any follow up medication until 9:20 pm when she received Morphine 10 mg for severe pain/dyspnea. During an interview with RN # 2 on 10/31/22 at 2:15 pm, RN # 2 confirmed staff did not medicate the patient for severe dyspnea as soon as possible.

Upon patient record review, 1 of 20 (Patient #17) 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 #17: On 9-6-22, the SN documented a call from the answering service that the patient needed a refill of Oxycodone and that the Percocet 5/325 was not effective. A refill for Oxycodone was implemented and the doctor was notified that the Percocet was not needed. However, there is no indication of Percocet being ordered for patient at any time during the provision of hospice services.

Based on policy review, clinical record review, and staff interview the nurse failed to timely assess for symptoms of a urinary tract infection (UTI) and to report symptoms for 1 of 1 patient with a UTI (#1). Findings included: A policy, Nursing Services, revised 3/17/22, was provided by Employee #1 on 8/17/22 at 5:15 p.m. The policy stated, "The hospice nurse must ensure that the nursing needs of the patient are met as identified in the patient's initial assessment, comprehensive assessment, and updated assessments. Hospice nursing services include patient assessment, pain and symptom management, identifying and preventing undesirable or secondary symptoms, provision of comfort needs for the patient, patient/family education, collaborating with other IDT [interdisciplinary team] members in the development of the plan of care ...The aide will notify the nurse case manager & IDT of concerns or change in the patient's condition. The nurse is responsible for interpreting information and implementing any needed changes in the Plan of Care." Patient #1 was admitted on 12/24/21 with diagnoses of Alzheimer's disease, moderate protein-calorie malnutrition, and a history of prostate cancer. The Plan of Care for 3/24/22-6/21/22 included orders for skilled nursing one to three times per week for 14 weeks with eight as needed visits; and hospice aide twice per week for one week, three times per week for 12 weeks, and one time for one week. On 6/11/22, the hospice aide conducted a visit and noted, " ...patient urinated and seem [sic] to be in pain emailed patient nurse ..." During an interview with Employee #1 on 8/18/22 at 4:46 p.m., it was revealed that the hospice aide should have called the nurse regarding pain instead of emailing. There was no evidence of nursing follow up regarding the painful urination until the SN visit on 6/8/22. The nurse's note stated, "Wife stated that patient had blood tinged [sic] urine over 2 days, but seemed to be resolving." The visit note did not include a temperature. On 6/17/22, the RN called the patient's spouse. The note stated, "Wife states patient was diagnosed with a UTI per Dr. _____ and has been prescribed generic Bactrim DS [an antibiotic]." The record review revealed Patient #1 was treated for a UTI in April 2022 as well. An interview with Employee #1 and Employee #2 on 8/18/22 at 5:09 p.m. confirmed nurse follow-up should have occurred prior to 6/11/22 since the aide report of pain. An interview with Employee #3 on 6/11/22 at 5:09 p.m. revealed the nurse may not have reported the symptoms after the 6/11/22 visit because hematuria was "resolving." The interview confirmed the patient had a history of UTIs and prostate cancer.