Every finding on record at Bellview Hospice Care, Inc

Upon patient record review, 2 of 14 (Patient #1,2) 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 1: During home visit, the caregiver stated that the patient was not receiving the Colace at the ordered frequency of 2 times a day. CG stated that she gives the Colace as needed, depending on when the patient's last bowel movement occurred and if he was have diarrhea stools. Neither of those instructions were present on active medication profile. COS - New orders written to change the frequency to twice a day as needed and to include instructions for how many days to wait before treating constipation and what to do in the event of diarrhea. Patient 2: Active medication profile duplicate drug therapy. Biscolax 10mg supp PRN daily and Dulcolax 10mg supp PRN daily both listed to treat constipation. Corrected on site, new orders written to remove Biscolax from the active medication profile.

Upon patient record review 2 of 14 (Patient #1,6) 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 1: Plan of care has an Aide frequency ordered as 2 times weekly starting on 02/17/2025. No evidence that the Aide completed 2 visits for the weeks of 03/16/2025-03/22/2025 and 06/29/2025-07/05/2025. No evidence that an order was to received to decrease visits for those weeks. No evidence that the visits, for either weeks, were missed at the request of the patient/caregiver. Patient 6: Plan of care has orders for patient to be showered during aide visits. No evidence that the patient received a shower on 08/09/2025. The aide documented that a bed bath was given instead of the shower at the request of the patient. No evidence that the aide notified the RN case manager of the patients request or that a change in the plan of care was needed.

Observed in Competency Session. In 7 of 7 HR files reviewed, the organization did not provide emergency preparedness training to staff, volunteers, and individuals providing on-site services under arrangement at the following intervals: - Initial training - At least every two years. During the competency session, it was learned that emergency training was only provided as part of new employee orientation. This was confirmed during the Emergency Management tracer. This was reviewed with the Administrator, Administrator Designee, DPCS and DPCS Designee.

Observed in Record Review. In 2 of 11 patient records reviewed, the hospice failed to complete a bereavement assessment as part of the initial comprehensive assessment. There was no documentation of this in records of RR#5 and RR#6.. This was reviewed with the Administrator, Administrator Designee, DPCS and DPCS Designee.

Observed in Record Review. In 11 of 11 patient records reviewed, where the interdisciplinary group met more than twice, the organization did not update comprehensive assessments to include progress towards desired outcomes. In addition, IDG notes did not include documentation of on-going patient decline, and plans for the next two weeks. This was reviewed with the Administrator, Administrator Designee, DPCS and DPCS Designee.

Observed in Record Review. In 11 of 11 patient records reviewed, the hospice did not develop plans of care that were based on the patient’s goals and the time frames, settings, and services required to meet those goals. For example, most goals were generic and did not include specific, measurable, attainable, relevant, and/or timed outcomes. Also, each goal was to be achieved by the date of the next IDG meeting, and none had been revised or closed since admission. This was reviewed with the Administrator, Administrator Designee, DPCS and DPCS Designee.

Observed in Record Review. In 10 of 11 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including measurable outcomes anticipated from implementing and coordinating the plan of care. For example, comprehensive assessments indicated that patients were at risk for falls, yet this was not addressed in the plans of care. This was reviewed with the Administrator, Administrator Designee, DPCS and DPCS Designee.

Observed in Record Review. In 1 of 11 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including medications and treatment necessary to meet the patient’s needs. For example, in the record of RR#3 oxygen equipment was ordered upon admission. Leaders confirmed that the patient was using oxygen, however there was no order in the plan of care identifying how it was to be delivered and the liter flow to use. This was reviewed with the Administrator, Administrator Designee, DPCS and DPCS Designee.

Observed in Patient Home. The hospice did not provide the patient with care according to the individualized plan of care. At HV#2 the CHHA stated that she would not be shampooing the patient because it was done yesterday. When asked, she stated that when this has happened in the past, she has not notified anyone. This was reviewed with the Administrator and DPCS Designee.

Observed in Patient Home. The hospice did not implement the infection prevention and control activities it had planned. During HV#2 the surveyor observed hand hygiene done by a CHHA. She did not rub her hands together for at least 20 seconds after applying soap, nor did she use a paper towel or other barrier to turn off the tap. This was reviewed with the Administrator and DPCS Designee.

Observed in Record Review. In 4 of 5 patient records reviewed, there was no documentation that the patient’s physician was notified of discharge in records RR#5, RR#6, RR#7 and RR#8 where the patient was discharged alive or died, . This was reviewed with the Administrator, Administrator Designee, DPCS and DPCS Designee.