Every finding on record at Carrolton Home Care, LLC.

Upon patient record review, 2 of 5 (Patient #3,4) 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 3: Current supply list has wound care supplies listed. No evidence that the patient has had a wound during the time on service. Patient 4: Current DME supply list has an oxygen concentrator listed. The medical record indicated that oxygen was discontinued on 05/12/26. No evidence oxygen concentrator was removed from the DME supply list at that time.

Upon patient record review, 1 of 5 (Patient #3) 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 3: Social worker interventions include "no additional visits to be provided". The medical record has orders for the social worker to complete monthly visits. No evidence that the plan of care was updated to remove those interventions at the time that the medical record was reviewed.

Upon patient record review, 8 of 27 (Patients #4,#5,#8,#9,#12,#14,#16,#18) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 4: Upon home visit medication reconciliation, the facility and hospice medication profiles did not match. The facility profile contained Miralax as a PRN medication instead of scheduled on hospice profile, did not contain scheduled donepazil that was on hospice profile, contained acetaminophen, ondansetron and Mylanta PRNs that were not on hospice profile, and contained scheduled Aricept and docusate that were not on hospice profile. Patient 5: Upon home visit medication reconciliation, the facility and hospice medication profiles did not match. The facility profile did not contain scheduled olanzapine that was on hospice profile. Patient 8: The medication profile contained glucose tablets without a specification for when administration is appropriate, and duplicate listings of morphine and naproxen. Upon home visit medication reconciliation, the facility and hospice medication profiles did not match. The facility profile contained oxygen at 2 LPM and hospice had 2-4 LPM. Patient 9,18: The medication profile contained nitroglycerin tablet every 5 minutes without instructions for a maximum amount of consecutive doses. Patient 12: The medication profile contained duplicate listings of senna. Patient 14: Upon home visit medication reconciliation, the facility and hospice medication profiles did not match. The facility profile did not contained scheduled acidophilus that was on hospice profile. Patient 16: Upon home visit medication reconciliation, the facility and hospice medication profiles did not match. The facility profile contained Ativan scheduled twice daily instead of once daily at bedtime on hospice profile, and contained a scheduled Linzess and PRN senna that were not on hospice profile.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 2 of 27 (Patients #15,#17) 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 15: The medical record contained documentation identifying patient wound on bilateral buttocks. There was no evidence of weekly wound measurements and assessments since 3/23/26 as required per agency policy. Patient 17: The medical record contained documentation identifying patient wound on left calf. There was no evidence of weekly wound measurements and assessments since 3/20/26 as required per agency policy.

Upon patient record review, 2 of 27 (Patients #8,#13) 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 8: The medical record indicated the patient was on services for heart disease and had use of oxygen since admission. There was no evidence of problems, goals, and interventions related to cardiac and respiratory dysfunctions included in the plan of care. Patient 13: The medical record contained diagnoses of bradycardia and hypertension that were supported with vitals documentation. There was no evidence of problems, goals, and interventions related to cardiac dysfunction included in the plan of care.

Upon patient record review, 9 of 27 (Patients #4,#5,#8,#9,#10,#11,#14,#16,#18) 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 4: Upon home visit medication reconciliation, the facility and hospice medication orders did not match. The facility orders contained Miralax as a PRN medication instead of scheduled on hospice profile, did not contain scheduled donepazil order that was on hospice medical record, contained acetaminophen, ondansetron and Mylanta PRN orders that were not on hospice record, and contained scheduled Aricept and docusate orders that were not on hospice record. The record also contained nursing documentation identifying the patient had a feeding tube since admission. There was no evidence of an order for the tube insertion site care, and flushing or maintenance. Patient 5: Upon home visit medication reconciliation, the facility and hospice medication orders did not match. The facility record did not contain a scheduled olanzapine order that was on hospice profile. Patient 8: The medical record contained an order for glucose tablets without a specification for when administration is appropriate. Upon home visit medication reconciliation, the facility and hospice medication orders did not match. The facility profile contained an oxygen order at 2 LPM and hospice had 2-4 LPM. Patient 9,18: The medical record contained an order for nitroglycerin tablet every 5 minutes without instructions for a maximum amount of consecutive doses. Patient 10: The medical record contained nursing documentation 2/27/26 identifying patient had a g-tube placed. There was no evidence of an order for the tube insertion site care, and flushing or maintenance. Patient 11: The medical record contained nursing documentation since admission identifying patient has a colostomy. There was no evidence of an order for colostomy maintenance. Patient 14: Upon home visit medication reconciliation, the facility and hospice medication orders did not match. The facility profile did not contain an order for scheduled acidophilus that was on hospice record. Patient 16: Upon home visit medication reconciliation, the facility and hospice medication orders did not match. The facility contained an order for Ativan scheduled twice daily instead of once daily at bedtime on hospice record, and the facility contained orders for scheduled Linzess and PRN senna that were not on hospice record.

Upon patient record review, 6 of 27 (Patients #1,#2,#8,#12,#13,#15) 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 medical record contained nursing documentation upon recertification assessment 2/24/26 identifying patient use of a wheelchair. There was no evidence of an order for the DME included in the plan of care. Patient 2: The medical record contained nursing documentation 4/3/26 identifying patient use of a sit to stand mechanical lift. There was no evidence of an order for the DME included in the plan of care. Patient 8: The medical record contained nursing documentation upon recertification assessment 2/16/26 identifying patient use of an APP mattress. There was no evidence of an order for the DME included in the plan of care. Patient 12: The medical record contained nursing documentation since admission identifying patient use of a wheelchair, and bedrails since recertification assessment 3/18/26. There was no evidence of orders for the DME included in the plan of care. Patient 13: The medical record contained nursing documentation upon recertification assessment 3/2/26 identifying patient use of a wheelchair. There was no evidence of an order for the DME included in the plan of care. Patient 15: The medical record contained an order for nebulized medications. There was no evidence of an order for the nebulizer included in the plan of care.

Upon client record review, 2 of 27 (Patients #2,#19) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient 2: The election form identified the patient elected a community physician as their attending. There was no evidence of collaboration with the attending for review of the plan of care since 2/25/26. Patient 19: The election form identified the patient elected a community physician as their attending. There was no evidence of collaboration with the attending for review of the plan of care since 3/5/26 until start of survey 4/6/26.

Upon patient record review, 2 of 27 (Patients #4,#15) 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 4: The medical record contained an order for the patient to receive Jevity tube feedings three times daily if the patient consumes less than 50% of each meal. There was no evidence the plan of care was updated to reflect the change in nutrition interventions from scheduled every four hours, to as needed. Patient 15: The medical record contained nursing documentation upon recertification assessment 2/9/26 identifying patient had multiple medication changes for agitation. There was no evidence the plan of care was updated to include problems, goals, and interventions related to agitation.

Upon client record review, 3 of 27 (Patients #7,#11,#20) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 7: The medical record contained an order for spiritual care visits once weekly. There was no evidence of a visit completed the week of 3/1/26. Patient 11: The medical record contained an order for nurse visits twice weekly. There was no evidence of a second visit completed the week of 3/8/26. Patient 20: The medical record contained an order for social worker visits once monthly. There was no evidence of visits completed in February and March 2026.

Upon patient record review, 1 of 27 (Patient #10) did not have evidence that the IDG documents the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Patient 10: The medical record contained nursing documentation 2/22/26 identifying patient received swallow training by a speech pathologist. There was no evidence of speech therapy assessment or treatment documentation.

Upon patient record review, 5 of 27 (Patients #2,#6,#10,#11,#20) did not have evidence in the patient record that hospice aide assignments and duties are: • Specific to patient needs. • 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. Patient 2: The medical record contained nursing documentation 4/3/26 identifying patient use of a sit to stand mechanical lift. There was no evidence of instructions for transfer assistance required on the aide care plan. Patient 6: The aide care plan contained bathing tasks for bed baths every visit and showers every visit. Patient 10: The medical record contained nursing documentation since admission identifying patient use of a Purwick external catheter. There was no evidence of instructions for catheter use or care included on the aide care plan. Patient 11: The medical record contained nursing documentation since admission identifying patient has a colostomy. There was no evidence of instructions regarding the colostomy included on the aide care plan. Patient 20: The aide care plan contained task for routine catheter care. Nursing documentation 12/17/25 identified the catheter was removed.

Upon patient client record review, 1 of 27 (Patient #21) did not have evidence that each patient record contains Advance Directives. Patient 21: The plan of care identified the patient was DNR. There was no evidence of an Advance Directive in the medical record.

Upon patient client record review, 1 of 27 (Patient #1) 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 1: The medical record contained nursing documentation upon recertification assessment 2/24/26 identifying patient has dyspnea with minimal exertion. After agency investigation, the documentation was in error and did not reflect patient condition.

Based on agency policy, clinical record review, and staff interviews, the agency failed to include oxygen and suctioning in the plan of care for 1 of 1 patient with suctioning (patient #1).Finding included: --- A policy, The Plan of Care (revised 12/31/2025) received on 01/12/2026 at 2:20 PM from the administrator stated, “The written plan of care will contain, but not limited to, the following: … DME [durable medical equipment] and medical supplies necessary to meet the patient needs…”Patient #1 was admitted on 09/19/2025 with a diagnosis of malignant neoplasm of colon (colon cancer). The plan of care or 09/19/2025-12/17/2025 included orders for skilled nurse (SN) visits 2 times a week for 1 week, 3 times a week for 2 weeks for 10 weeks, 1 time a week for 1 week, and 3 PRN (as needed).  Review of the clinical record revealed that on 09/24/2025 Registered nurse (RN) #5 documented, “PT [patient] breathing is labored … Daughter removes phlegm [thick mucus] with use of suctioning… suction machine ordered…” Further review revealed that a physician’s order for oxygen and suctioning were not included in the plan of care.During an interview conducted on 01/12/2026 at 1:28 PM RN #5 stated, “There should be an order in there if she has it… Yes, it should be added to the plan of care.”During an interview conducted on 01/12/2026 1:39 PM the administrator stated, “Always get an order from the physician and add it to the plan of care.”

Based on agency policy, clinical record review, and staff interviews, the agency failed to document providing instructions for proper use of durable medical equipment (DME) for 1 of 3 patients with DME (patient #1).Findings included: --- A policy, Clinical Record (revised 12/3/12025) received on 01/12/2026 at 2:17 PM from the agency administrator stated, “A clinical/service record will be initiated and maintained for each patient… and will include at a Minimum: … Documentation of any/all education provided to the patient/caregiver…”Patient #1 was admitted on 09/19/2025 with a diagnosis of malignant neoplasm of colon (colon cancer). The plan of care or 09/19/2025-12/17/2025 included orders for skilled nurse (SN) visits 2 times a week for 1 week, 3 times a week for 2 weeks for 10 weeks, 1 time a week for 1 week, and 3 PRN (as needed).  Review of the clinical record revealed that on 09/24/2025 Registered nurse (RN) #5 documented, “PT [patient] breathing is labored … Daughter removes phlegm [thick mucus] with use of suctioning… suction machine ordered…” Further review revealed that no education to the patient/caregiver was documented on how to use the suction machine.An interview with RN #5 on 01/12/2026 at 1:28 PM revealed that interventions on education should be included in the plan of care.An interview with the administrator on 01/12/2026 at 1:39 PM revealed that when an order is added to the plan of care education to the patient/family should be added.

Based on agency policy, clinical record review, and staff interviews, the agency failed to document caregiver problems for 1 of 1 patient with a discharge for cause (patient #1)Findings included: --- A policy, Clinical Record (revised 12/12/2025), received on 12/15/2025 at 2:23 PM from the agency director stated, “A clinical/service record will be initiated and maintained for each patient receiving care… and will include at a minimum… Patient/family response to care/services provided… Entries into the clinical record will be clear, concise, and specific statements of fact.”A policy, Live Discharge and Discharge Planning Process (revised 11/05/2025) received on 12/15/2025 at 12:52 PM from the agency director stated, “Document the problem(s)…”Patient #1 was admitted on 04/19/2024 with a diagnosis of dysphagia (difficulty swallowing) following a cerebral infarction (brain tissue death following a blood clot). The plan of care for 08/15/2025-10/13/2025 included orders for skilled nurse (SN) visits 1 time a week for 8 weeks with 4 PRN (as needed) and home hospice aid (HHA) visits 1 time a week for 1 week, 5 times a week for 8 weeks, and 1 time a week for 1 week. A review of the clinical record revealed that registered nurse #4 documented that the patient was discharged due to, "CG [caregiver] using inappropriate language with staff." Further review revealed that there was no documentation of the caregiver using inappropriate language with the staff.An interview with the agency director on 12/15/2025 at approximately 1:45 PM revealed that the caregiver was using inappropriate language with HHA #5. 26 of 26 HHA visits conducted between 08/15/2025 and 10/02/2025 were documented with no indication of problems with the caregiver.An interview conducted on 12/15/2025 at 2:00 PM with HHA #5 revealed that they failed to document the caregiver problems and failed to document notifying the registered nurse. HHA #5 stated that sometimes they document aggression.An interview conducted on 12/15/2025 at 2:04 PM with the agency director revealed that caregiver problems and conversations with the registered nurse should be documented in the clinical record.

Upon observation, there was no evidence the patient has the right to voice grievances/complaints regarding treatment or care that is (or fails to be) furnished and lack of respect of property by anyone who is furnishing care/service on behalf of the hospice. Patient #22 The patient record reflects a request for transfer to another hospice due to issues with delivery and service of the DME. The agency verbalizes agreement with this, but is unable to provide documentation of the patient/family complaint or the attempts for resolution.

Upon patient record review, 1 of 27 (Patient #8) did not have evidence that the patient has received effective pain management and symptom control from the hospice for conditions related to the terminal illness. Patient #8 The patient reported pain of 7/10 during nursing visits on 2/14/23, 2/21/23, 2/23/23, 4/17/23, 4/25/23 and an 8/10 on 3/3/23 and 3/28/23. The patient reported taking medication prior to the RN arrival or the patient would take a dose of medication during the nursing visit. There is no documentation to support that nursing staff made a follow up call or reassessment of the patients response to the pain medication.

Upon patient record review 1 of 27 (Patient #27) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #27 The patient was admitted on 2/8/22, the spiritual assessment was completed on 2/18/22.

Upon patient record review 4 of 27 (Patient #7, 16, 19, 24) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #7 The patient was admitted on 9/7/21, there is no evidence in the patient records that a spiritual care assessment was completed by the RN, SW or SCC at the time of admission or to date. Patient #16 The patient was admitted on 6/24/22 spiritual care services were declined and a spiritual assessment was not completed by the RN, SW or SCC. (Corrected on site.) Patient #19 The patient was admitted on 4/20/23, there is no spiritual assessment on record. The patient declined spiritual care and the assessment was not performed by the RN, SW or Spiritual Care provider. (Corrected on site.) Patient #24 The patient was admitted on 9/22/22, spiritual care services were declined and a spiritual assessment was not completed by the RN, SW, or SCC.

Upon patient record review, 8 of 27 (Patient #1, 5, 7, 8, 13, 16, 21, 23) 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 The medication profile includes orders for levothyroxine 125mcg daily started on 2/7/23, per the SNF the order was changed to levothyroxine 100mcg daily on 3/31/23 and not updated on hospice MAR. (Corrected on site.) Patient #5 The medication profile includes orders for Jevity 1.5 CAL every 6 hours, it does not include the total infusion amount and is written as an oral administration but should be administered via G-tube. (Corrected on site.) Patient #7 The medication profile does not include the information for the diluent of mixing and administering Miralax 17g Powder for the relief of constipation. (Corrected on site.) Patient #8 The medication profile includes orders for Nitroglycerin 0.4mg sublingual take 1 tab every 5 minutes and no more than 3 doses, it is not indicated as a PRN order. (Corrected on site.) Patient #13 The medication profile does not include an application site for Minerin topical cream. (Corrected on site.) Patient #16 The medication profile does not specify the application site for Diclofenac 1% topical gel. The medication profile does not specify the wound application site for Metronidazole 500mg crushed tablet. (Corrected on site) Patient #21 The medication profile does not specify the diluent to be used for the administration of Miralax 17gram powder, ordered on 8/6/21. Patient #23 The medication profile does not specify an application site for Diclofenac 1% topical gel ordered on 9/3/20.

Upon patient record review, 7 of 27 (Patient #7, 10, 14, 15, 21, 22, 23) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #7 The patient was admitted on 9/7/21, the initial bereavement assessment has not been completed. (Corrected on site) Patient #10 The patient was admitted on 5/25/21, the initial bereavement assessment was completed on 7/13/21. Patient #14 The patient was admitted on 12/7/22, the initial bereavement assessment was completed on 12/15/22. Patient #15 The patient was admitted on 2/7/23, the initial bereavement assessment was completed on 2/13/23. Patient #21 The patient was admitted on 8/4/21, the initial bereavement assessment was not completed. Patient #22 The patient was admitted on 1/31/20, the bereavement assessment was not completed. Patient #23 The patient was admitted on 4/24/20, the initial bereavement assessment was completed on 8/12/21

Upon patient record review, 3 of 27 (Patient #10, 13, 16) 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 #10 The plan of care does not include a problem statement with interventions and goals for the patients diabetes. The patient remains on insulin with nutritional deficits AEB weight loss from #184lbs to #134 since admit. (Corrected on site) Patient #13 The patient record reflects that the patient uses a special topical skin cream and an prescription shampoo for skin irritations, the plan of care does not include a problem statement with interventions and goals for the skin impairment. The patient was admitted to hospice services for COPD and uses oxygen, there is no problem statement with interventions and goals for respiratory related issues in the plan of care. (Corrected on site.) Patient #16 The plan of care does not include a problems statement with interventions and goals for the patients diabetes. The patient remains on insulin and has noted nutritional deficits. (Corrected on site.)

Upon patient record review, 8 of 27 (Patient #1, 5, 7, 8, 13, 16, 21, 23) 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 #1 The patient received lab services for a TSH level on 3/31/23 ordered by the hospice MD, the hospice POC does not include the lab order. The hospice medication profile includes orders for levothyroxine 125mcg daily that was discontinued on 3/31/23 per the facility medication record. The facility medication record indicates that a new order was received on 3/31/23 for levothyroxine 100mcg daily which is not included in the hospice plan of care. (Corrected during survey) Patient #5 The order on 4/12/23 for Jevity 1.5 CAL every 6 hours does not include the total amount to be infused. The order is written as an oral administration but the patient received nutrition via G-tube. (Corrected during survey) Patient #7 The medication order on 9/8/21 for Miralax 17G powder does not include the mixing diluent for the administration of the medication. (Corrected during survey) Patient #8 The order for Nitroglycerin 0.4mg sublingual is not entered as a PRN order. (Corrected during survey.) Patient #13 The medication order for Minerin Cream, apply topically 2 times a day does not specify where to apply the cream. (Corrected on site.) Patient #16 The medication order for Diclofenac 1% topical gel entered on 11/9/22 does not specify an application site. The medication order for Metronidazole 500mg tablet crushed does not specify which wound to apply the medication to (the patient has 3 documented wounds.) (Corrected on site.) Patient #21 The medication order for Miralax 17gr powder daily does not include a diluent to mix the medication for administration. Patient #23 The medication order for Diclofenac 1% topical gel ordered on 9/3/20, does not specify an application site. The patient record contains documentation on 1/19/23 that the RN performed a venous puncture lab draw and a "serum sample was delivered to UNC Health Southeastern." There are no orders in the patient record for labs.

Upon patient record review, 4 of 27 (Patient #1, 4, 13, 23) 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 patient receives wound care as ordered according to the plan of care, the hospice is not providing the facility with the wound care supplies. Patient #4 The patient is incontinent and uses adult briefs, there is no evidence in the plan of care of incontinent supplies. The patient receives wound care treatment, the plan of care does not include wound care supplies. There is no DME listed in the plan of care, there is evidence in the patient record that she requires an electric bed with an APP mattress documented on 1/16/23. (Corrected on site.) Patient #13 The patient uses oxygen, there is no oxygen on the patients supply list. (Corrected on site.) Patient #23 The patient has medication orders for nebulized Albuterol 1.25mg/3ml every 4 hrs as needed for wheezing, the plan of care does not include a nebulizer in the patient medical equipment list.

Upon patient record review, 7 of 27 (Patient # 2, 4, 7, 9, 10, 16, 24) 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 #2 The plan of care is not updated to include a problem statement with interventions and goals for treatment of a urinary tract infections on 4/20/23 (corrected on site ) and 10/18/22. The patient was treated for an eye infection on 2/10/23 with Sulfacetamide 10% which did not have a problem statement with interventions and goals. On 12/7/22 the patient was assessed for elevated temperature with tachycardia and wheezing and started on Albuterol nebulizer treatments for wheezing, the plan of care was not updated to include a problem statement with interventions and goals. Patient #4 The patient has wound care orders initiated on 1/15/23 and completed on 2/6/23, there was no update in the plan of care to include a problem statement with interventions and goals for treatment. (Corrected on site.) The plan of care does not contain a problem statement with interventions or goals for spiritual care. Patient #7 The plan of care does not include a problem statement with interventions and goals for wound treatment initiated on 2/28/23. The plan of care has not been updated to resolve the "Need for alternative visit method due to COVID-19 pandemic" although there is no evidence of restricted visits for the patient at this time. The plan of care is not updated to include a problem statement with interventions and goals for ongoing anxiety and agitation as documented on 2/24/23, 4/14/23 and 4/19/23. (Corrected on site.) Patient #9 The patient was moved into a long term care facility on 2/24/23, the plan of care does not include the coordination of care with facility staff. (Corrected on site.) Patient #10 The patient record reflects significant weight loss from #184lbs to #134lbs since admit, the patient is diabetic. There is no problem statement with interventions or goals for the nutritional management of the patient. (Corrected on site.) Patient #16 The patient record reflects a history of multiple urinary tract infections with antibiotic treatment initiated on 3/15/23 (Augmentin), 3/24/23 (Pyridium), 3/30/23 (Bactrim), and 4/12/23 (Augmentin) there is no problem statement with interventions and goals for the management of the infections. Patient #24 The patients plan of care was not updated to include a problems statement with interventions and goals for upper respiratory infection (documented on 1/4/23), COVID-19 infection (documented on 1/5/23 and 1/19/23) hip fracture with surgical repair (documented on 1/11/23) or coordination of care with other healthcare provider related to hospitalization on 1/11/23.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #2 During the home visit, it was witnessed that the visiting RN placed her nursing assessment tools on a bedside table without cleaning the table or using a barrier. After patient care, the RN cleaned her assessment tools and returned them to the bedside table (without a barrier) before returning them to her nursing bag, The RN placed her documenting tablet into the same single pocket bag as her nursing assessment tools. Patient #5 During the home visit, it was witnessed that the aide started to provide patient care with gloves on, the aide then reached into her supply bag to retrieve her documenting tablet with her gloves still on. The aide performed documenting tasks, then returned the tablet to her bag and continued to provide patient care with the same gloves on her hands.

Upon patient record review, 1 of 27 (Patient #14) 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 #14 The hospice aide plan of care does not indicate a frequency for bathing, dressing, ear care, hair care, incontinence care, nail care, assist to toilet, oral care, perineal care, shampoo, shaving, skin care, changing linen or emptying trash. (Corrected on site)

Upon patient record review 2 of 27 (Patient #13 and 23) 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 #13 The aide plan of care does not include assigned tasks for bathing, per hospice aide interview, the aide provided a shower with the use of a shower chair on 3/27/23 and 4/26/23. Patient #23 The plan of care includes orders to start hospice aide services on 1/15/23 for 2 x a week, there was only 1 visit made on 1/19/23.

Upon client record review, 1 of 27 (Patient #23) did not have evidence that the discharge summary includes all required information. Patient #23 The patient discharge record does not include post discharge information for medication management. There is no evidence of a summary of care or evidence of notification provided to the patients primary care physician.

Upon client record review, 2 of 27 (Patient #1, 7) 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 #1 Orders for wound care on 1/20/23 do not specify the schedule for responsibility of wound care to be performed by facility nurse or the hospice nurse. (Corrected on site.) Patient #7 Orders for wound care on 3/1/23 do not specify the schedule for responsibility of wound care to be performed by facility nurse or the hospice nurse. (Corrected on site.)