Every finding on record at Caring Nurses Hospice Inc

Upon patient record review, 1 of 14 (Patient #1) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, specifically medications and treatments: Patient #1: A verbal order was obtained on 08/25/25 for, "Left buttocks wound. Cleanse with NS/WC, pat dry, apply Zinc Oxide, cover with border dressing. Daily and prn when soiled." This is not a complete wound treatment order, as it does not include 'who' will be providing this daily dressing intervention on days the Hospice nurse is not visiting. This patient lives in a Group Home setting.

Upon patient record review, 2 of 14 (Patients #1 and 3) did not contain evidence that the revised Plan of Care included information from these patients' updated comprehensive assessment(s): Patient #1: The IDG POC dated 09/03/25 includes an order for, "Oxygen 2-5 lpm via NC continuous." During the Surveyor-attended home visit on 09/16/25 the Group Home staff was interviewed, and reported that the patient has not used Oxygen in several months. Patient #3: A verbal order was obtained on 10/08/24 for, "May suction oral cavity and nasopharyngeal region as needed." This individualized patient intervention is not included on the current IDG POC dated 09/17/25.

Upon personnel record review, 1 of 12 (Personnel #8) did not contain evidence that a Skills Competency Evaluation had been conducted per CMS guidelines: Personnel #8: DOH 06/06/23. An Aide Skills Competency was conducted on 06/06/23. However, the following required skill was not evaluated for/documented: The physical, emotional, and developmental needs of, and ways to work with, the populations served by the Hospice.

Upon patient record review, 1 of 14 (Patient #1) did not contain evidence that all entries were clear and complete: Patient #1: The SN home visit dated 08/25/25 documented, "Wound care was rendered per M.D. orders." This is not clear, detailed wound intervention documentation.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs. This standard was not met as evidenced by a review of clinical records, interviews, and observations. 1 of 3 (33%) home visits revealed the agency did not ensure the patient's drug profile included all over the counter drugs. Home Visit #0: The patient elected hospice care on 7/13/2022. During the home visit conducted with the licensed vocational nurse (Staff #6) on 8/24/2022, the patient rated his pain level as a 6 and stated he takes Tylenol for pain. Review of the drug profile in the patient's home and the drug profile in the clinical record revealed the OTC Tylenol was not included as one of the patient's current medications. The administrator, present at the home visit on 8/24/2022, confirmed that Tylenol was not listed on the drug profile.