Every finding on record at Circle of Friends Palliative Care Inc

Upon patient record review, 1 of 4 (Patient #4) 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 #4) The patient's medication profile contains orders for Ipratropium Bromide/Albuterol Sulfate 0.5 mg-3mg/3ml solution for inhalation. The patient did not have this medication available for use.

Upon patient record review, 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. No patient records to review. No admissions since compliance date of 5/28/25.

Upon patient record review, 1 of 4 (Patient #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 medications and treatments. Patient #4) The patient's current plan of care dated 7/4/25 contains orders for Ipratropium Bromide/Albuterol Sulfate 0.5 mg-3mg/3ml solution for inhalation. The patient did not have this medication available for use.

Upon patient client record review, did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 No patients admitted since compliance date of 5/28/25.

Upon client record review, did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. There have not been any patients transferred since compliance date of 5/28/2025.

Upon observation, there was no evidence the patient record, whether hard copy or in electronic form, is made readily available on request by an appropriate authority. Surveyor requested access to Hospice MD at 9:20 AM obtained access at approximately 11:10 AM.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review, 10 of 14 (Patient # 1,2,3,4,5,6,7,8,9,10) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patients 1-10: The RN comprehensive assessment did not contain evidence that imminence of death was being assessed.

Upon patient record review, 4 of 14 (Patient #3,5,9,14) 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 two orders for Acetaminophen Rectal 650 and a 325 rectal suppository both Q6 hours prn, and 2 orders for Acetaminophen 500mg PO Q6 hours prn. The medication profile does not show evidence of frequency for Oxygen order 2-5 L. Corrected on site. In addition, the family showed the surveyor a basket of patient medications including Tradjenta 5mg 1 tab daily, Tamsulosin HCL 0.4mg 1 cap po daily at HS, and Pantoprazole 40mg 1 tablet po daily. There is no evidence of these medications. There is no evidence of documentation that patient/family should discontinue these medications noted in the medical review upon admission to services. Corrected on site Patient 5: The medication profile contains an order for Acetaminophen 650mg rectally Q6 hours PRN and Acetaminophen 500mg Q6 hours prn. There was no directive not to exceed max allowable daily dose. Patient 9: The medication profile contains an order for Preparation H with a dose of 50% and does not include dosing and frequency. Patient 14: The medication profile contains Tylenol 650mg Q4 hours PRN and Norco 5/325mg Q6 hours PRN though did not contain the do not exceed max allowable daily dose.

Upon patient record review, 1 of 14 (Patient #8) 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 8: There was no Bereavement assessment completed within 5 days of SOC.

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

Upon patient record review, 1 of 14 (Patient #6) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient 6: The SN documented on 12/21/24 “ Redness to under breasts and left arm”. There was no evidence of education being provided to the patient or caregiver on how to care for the red areas.

Upon patient record review, 2 of 14 (Patient #7,9) 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 7: The SN documented in SN notes 12/17/24 and 12/12/24, patient high fall risk and high aspiration risk. There was no nursing care plans with goals and interventions for falls or risk for aspiration. Patient 9: The SN documented on the Initial Comprehensive Assessment patient is a high aspiration risk. There was no nursing care plan for risk for aspiration with goals and interventions. In addition, the POC contains a DNR order which is inconsistent with the POLST DNR which contains a DNR/care level RC comfort care.

Upon patient record review, 4 of 14 (Patient #1,7,8,11) 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: Patient 1: The POC 11/29/24 contains order for SC visit within 5 days and PRN and MSW within 5 days and PRN there was no frequency for the PRN visit. Corrected on site Patient 7: The POC 11/25/24 contains an order for MSW and SC PRN with no quantifier. Patient 8: The POC contains orders for SC 1 time and PRN and MSW 1 time and PRN. There is no frequency for the PRN. Patient 11: The POC 11/10/23 contains orders for MSW and SC for visits PRN with no quantifier.

Upon patient record review, 6 of 14 (Patient #2,3,5,9,11,14) 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 2: The SN documented on 5/10/25 “pt took a few sips of Ensure.” Ensure was not included on the POC. Corrected on site Patient 3: Upon home visit finding, the following medications were found in home; Tradjenta 5mg 1 tab daily, Tamsulosin HCL 0.4mg 1 cap po daily at HS, and Pantoprazole 40mg 1 tablet po daily. There is no evidence of these medications on the POC. The POC contains orders for Oxygen 2-5 L with no frequency. The POC 5/10/25 contains two orders for Acetaminophen Rectal 650 and a 325 rectal suppository both Q6 hours prn, and 2 orders for Acetaminophen 500mg PO Q6 hours prn. These are duplicate orders for rectal suppositories and PO acetaminophen. The POC contains Calmoseptine with no directives. Corrected on site Patient 5: The POC contains an order for Acetaminophen 650mg rectally Q6 hours PRN and Acetaminophen 500mg Q6 hours prn. There was no instruction not to exceed max allowable daily dose. Patient 9: The POC 11/15/24 contains an order for Preparation H with a dose of 50% and does not indicate proper dosing or frequency. The wound care orders on the POC do not state who is to perform the wound care. SN documented on 12/26/24 and 12/20/24 patient wears compression stockings. There is no order on the POC for compression stockings. Patient 11: The POC 11/15/23 contains an order for Calmoseptine with a dose of 1 ointment. There no directive of how much ointment to apply. Patient 14: The POC 3/15/25 contains Tylenol 650mg Q4 hours PRN and Norco 5/325mg Q6 hours PRN though did not contain not to exceed max allowable daily dose. The POC contains an order for colostomy care daily with no directives of what type of care to provide and who is to provide the care and change foley monthly with no directives of size of foley, flushing directives, or who to to provide the care. The POC contains wound care orders though does not state who is to perform the wound care.

Upon patient record review, 3 of 14 (Patient #2,8,9) 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 2: The comprehensive assessment contains evidence the patient has a wheelchair. This was not included on the POC. Corrected on site Patient 8: The SN documented on 12/16/24 “patient transferred with Hoyer lift” The Hoyer lift was not included on the POC. Patient 9: The SN documented on 1/11/25 patient uses cane. There was no order for a cane on the POC.

Upon patient record review, 1 of 14 (Patient #4) 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 4: The IDG on 5/15/25 does not contain evidence the SC was present as there is no signature by the SC. Spiritual care was actively involved with the patient therefore there was no evidence of collaboration since there was no signature to validate participation.

Upon patient record review, 1 of 14 (Patient #1) 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 1: The medical record does not have any aide visits since 12/16/24. The IDG still contains an order for aides twice weekly. The SN did not update the POC. Corrected on site

Upon patient record review, 5 of 14 (Patient #2,3,7,9,14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: The POC 5/6/25 contains an order for SN once weekly and LVN once weekly. The RN saw the patient on 5/6/25 and 5/10/25 with no evidence of the second visit being PRN. The LVN did not see the patient the first week. Patient 3: The SN documented on 4/24/25 “ SN educated family on applying warm compress to area.” There is no evidence of an order for this modality. Patient 7: The POC 11/25/24 contains an order for SN 1 time per week. There was no SN visits 1/5/25-1/11/25 or 12/22/24-12/28/24. There was no missed visit documentation, evidence physician order to decrease visits or evidence of refusal. Patient 9: The SN documented on 12/30/24 that patient has slight redness to right breast fold and is applying Calmoseptine on it and it comes and goes. There is no order for Calmoseptine to be applied to the breast area until 1/8/25. In addition, SN documented on 12/26/24 and 12/20/24 patient wears compression stockings. There is no order on the POC for compression stockings. Patient 14: The SN documentation on 4/10/25 for wound care is completed by restating the physician order including frequency. The care was not in past tense to indicate the SN completed the wound care.

Upon patient record review, 1 of 14 (Patient #4) 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 4: The SN documented on 5/3/25 “Random blood sugar 335mg/dl educated patient on no sugar diet. Pt forgot to take their meds this am.” There is no evidence the SN notified the MD of the elevated blood sugar level. Patient 6: On 9/29/24 the NP documented “Pt c/o redness and itching right away. Redness to skin folds with towels under skin folds due to moisture.” The SN documented on12/21/24 “ Redness to under breasts and left arm”. MD not notified of redness that continued from September to December 2024 and there was no order placed for Nystatin until 12/24/24.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 12 (Personnel #5) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) Personnel 5: The aide competency did not contain evidence of the aide performing shampoo in a sink, tub and bed or a sponge bath.

Upon patient record review, 8 of 14 (Patient #1,2,3,4,7,8,9,11) did not have evidence in the patient record that hospice aide assignments and duties are: Patient 1: The aide POC 11/29/24 contains an order for diet as tolerated. The diet order on POC 11/29/24 is for a pureed diet. Corrected on site Patient 2: The aide POC 5/6/25 contains an order for turn and reposition, encourage fluids and change linens with no frequency, also listed on the aide POC is dress in both street clothes and PJ’s every visit. Diet as tolerated and POC diet is Mechanical soft. Corrected on site Patient 3: The aide POC 4/2/25 contains the following orders with no frequency: turn and reposition, feed patient, encourage fluids. Corrected on site Patient 4: 1/22/25 contains an order for diet as tolerated NAS. The POC 1/22/25 order is for a mechanical soft diet NAS. The aide POC contains orders to dress patient in both street clothes and pajamas and would require the aide to decide which is appropriate to dress the patient in. Corrected on site Patient 7: The aide POC 11/25/24 contains directives to change linens, street clothes and pajamas, feed assist, encourage fluids with no frequency. The diet order was as tolerated on the aide POC it is mechanical soft on the POC. Patient 8: The aide POC 11/22/23 contains order to turn and reposition and change linens with no frequencies. The aide POC also contains orders for diet as tolerated. The POC contains orders for Mechanical soft diet. Patient 9: The Aide POC contains orders to dress patient in both street clothes and pajamas. It also contains an order for diet as tolerated and patient is on a mechanical soft per the POC. The aide POC contains change linens with no frequency. Patient 11: The aide POC 11/13/23 contains a directive to the aide to "take a picture of new skin issues and send to RN". This is not a practice the agency uses verified by Administrator. The aide POC has directive to dress in pajamas and street clothes, change linens no frequency, record BM with no frequency and measure urine output with no frequency.

Upon patient record review 6 of 14 (Patient #1,2,3,4,7,9) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 1: The POC 11/29/24 contains an order for aides 3 times per week. The aides first visit was not until 12/2/24. There was no evidence of refusal or any missed visit documentation. There are no aide visits documented past 12/16/24. There was no order to discontinue the aide. Corrected on site Patient 2: The POC 5/6/25 contains an order for aide once weekly. There have been no aide visits documented as of survey. Patient 3: The POC 4/16/25 contains an order for aide twice weekly. The first aide visit was not until 4/21/25. There is no evidence of missed visit documentation, order to decrease visits or refusal. Patient 4: The POC 1/15/25 contains an order for aide twice weekly. The week of April 13, the aide saw the patient on April 14,16,19. The week of April 20, the aide saw the patient once on April 25. The week of April 27, the aide saw the patient on 4/30/25. There was no evidence of orders to increase aide visits or decrease aide visits. There was no missed visit documentation or evidence of refusal. There are no aide visit documented past 4/30/25. There was no order to discontinue aides. Corrected on site Patient 7: The POC contains an order for aide 3 times per week. The week of Nov 24, the aide saw patient on 11/27 only. The week of 12/31/24, the aide saw the patient on 1/3 and 1/6. The week of Dec 22, the aide saw the patient once on 12/23. There is not evidence of missed visit documentation, changes to orders or refusal of visits by the patient. Patient 9: The POC 11/15/24 contains an order for aide 1 time per week. The week of 11/24/24 there were no aide visits made. The week of 12/1/24 there were 2 visits made with no order to increase visits. The week of 12/15/24-12/21/24 there were no visits made. The week of 12/22, there were 2 visits made. There was no evidence of any orders for increasing or decreasing visits at these times and no evidence of refusal by the patient and no missed visit documentation. The aide documented performing the following tasks that were not ordered on 12/28/24: fall precautions, objects in reach, bed in low position. The aide did not perform the following ordered tasks provide incontinence care, dress in pajamas, shower, brush hair. On 12/22/24, the aide performed objects in reach, bed in low position, turn and reposition which were not ordered by the SN. The aide did not provide the following that were ordered by the SN: dress in pajamas, shower, and shampoo.

Upon contract review, 1 of 3 (Garden Park) did not have evidence the agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Authorized by the hospice • Furnished in a safe and effective manner by qualified personnel • Delivered in accordance with the patient's plan of care Garden Park contract: The contract has a statement of "SNF shall notify SIRIUS HOSPICE INC of any modifications to the patient care or place of service in the event of any crisis situations...SNF staff shall discuss such modifications with SIRIUS HOSPICE INC. prior to making any changes." The agency name is Circle of Friends Palliative Care. The section XIV Relationship of the parties has the SIRIUS HOSPICE INC name as well. Corrected on site.

Condition of Participation: Clinical Records.

Upon patient record review, 2 of 14 (Patient #4,7) did not have evidence that each patient record contains: Patient 4: The EOB did not include an effective date of when services begin. The area was left blank. Patient 7: The medical record contains evidence the patient request to receive the written copy of non-covered items, services, and/or meds unrelated to terminal illness on Hospice Election Addendum. The caregiver was given the form and the form was signed but the form was blank it did not include the covered terminal diagnosis.

Upon patient record review, 4 of 14 (Patient #4,6,7,8) 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 4: The MSW documented on 5/14/25 “All CRs are in place.” This is not an approved abbreviation. Patient 6: On 1/6/25 the SN documented pain is a 0/10 in the pain area and then documented pain is a 6/10 to bilateral legs in the narrative. In addition, the SN notes from 11/23/24 through discharge were not approved by the DPCS and remain unsigned by the RN. In addition, the SN documented on 12/14/24 “BP medication was administered per plan of care” unclear documentation of what was administered. Patient 7: The SN documented on the initial comprehensive assessment: Pt is confused. The question of is patient uncomfortable because of pain was answered yes. The SN also documented there was no recent symptoms of pain reported. Then documented used SIT (Self Identified Threshold) scale to assess pain and rated pain a 2/10. There was no evidence the FLACC scale or any other pain scale appropriate for a confused patient was used. Patient 8: The SN documented on 1/16/25 the discharge summary “Pt decided to transfer to another hospice, order obtained to discharge from Tradition Hospice Care effective 1/16/25.” In addition, there are visits in the medical record on 1/7/25, 1/9/25, 1/14/25 that are not approved by the DPCS and remain unsigned by the RN.

Upon patient record review, 1 of 14 (Patient #8) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient 8: The patient transferred to another hospice. There is no evidence the transfer summary was sent to the receiving hospice.

Upon patient record review, 2 of 14 (Patient #7,9) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: Patient 7: The patient was discharged and there was no evidence a copy of the discharge summary was sent to the physician. Patient 9: The patient was discharged and there was no evidence a copy of the discharge summary was sent to the physician.

Upon patient record review, 4 of 14 (Patient #5,6,7,9) did not have evidence that the discharge summary includes all required information. Patient 5: The discharge summary did not contain the following required information: A summary of the patient's stay, including treatments, symptoms and pain management, The patient's current plan of care, the patient's latest physician orders, any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility. Patient 6: The discharge summary did not contain the following required information: A summary of the patient's stay, including treatments, symptoms and pain management, the patient's current plan of care, the patient's latest physician orders, any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility. Patient 7: The discharge summary did not contain the following required information: The patient's current plan of care or the patient's latest physician orders. Patient 9: The discharge summary did not contain the following required information: A summary of the patient's stay, including treatments, symptoms and pain management, the patient's current plan of care, the patient's latest physician orders, any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility.

Upon patient record review, 1 of 14 (Patient #8) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 8: The SN documented on 12/9/24 “Removed dressing, cleansed area and place new dressing. There is no order for a dressing change on the POC. The SN documented on 1/5/25 “Nodule cleansed, Bacitracin applied and covered with gauze. There was no order documented for this wound care until 1/8/25 IDG. The POC contains orders for SC 1 time and PRN and MSW 1 time and PRN both the MSW and the SC saw the patient at every recertification with no orders to increase visits.

Upon client record review,1 of 5 (Patient #5) did not have evidence that the IDG ensured that the care and services were provided in accordance with the plan of care. Patient #5: During the RN Initial Assessment, volunteer services were offered and were declined by the family. On 9/30/2022, a volunteer conducted an on-site visit. There was no documentation to indicate the plan of care was updated with Volunteer Services.