Every finding on record at Community Hospice, LLC

Upon patient record review 1 of 27 (Patient #19) 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 19: There was no evidence of a spiritual assessment.

Upon patient record review, 6 of 27 (Patients #1,#5,#10,#12,#13,#14) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 1: The medication profile contained Lumigan eye drops without instructions of whether to administer in both eyes or one eye. Patient 5: The medication profile contained Pepto-Bismol with no frequency, stating as needed without parameters for how often it can be administered. During home visit medication reconciliation, the daughter confirmed there was no oxygen in the home, patient's dose of metoprolol is 12.5 mg daily, and takes prevastatin 40 mg daily. The hospice profile contained oxygen, metoprolol 25 mg daily, and no prevastatin. Patient 10: Nursing Facility contains vit C 500mg BID, vit D3 5,000 units daily, methenam 1 gm HS, ibuprofen 400mg daily not on the hospice profile; the hospice profile has evista 60mg daily, meloxicam 15mg daily, and rasagiline 1 mg daily not on NF, NF has tylenol 325mg BID PRN and hospice has 650 mg Q6h PRN Patient 12: During home visit medication reconciliation, the son confirmed patient is taking cetirizine for allergies approximately for a month. There was no evidence of cetirizine included on the medication profile. Patient 13: The medication profile contained Voltaren topical gel with no area defined for administration. Patient 14: The medication profile contained a fluticasone inhaler with incorrect route via nasal cannula, and polyethylene glycol oral powder with no instructions to mix with a diluent.

Upon patient record review, 1 of 27 (Patient #1) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 1: There was no evidence of a physical assessment completed by an RN between 3/5/26 and 4/3/26. All nursing visits completing in between those dates were by an LPN. Per Gentiva's procedures an RN visit is required every 15 days.

Upon patient record review, 1 of 27 (Patient #6) 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 6: There was no evidence of wound measurements between discovery 3/19/26 and wound de-activation 4/14/26, and no assessments after 4/2/26. Agency policy requires weekly wound assessments and measurements.

Upon patient record review, 1 of 27 (Patient #17) 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 17: The plan of care included problems, goals, and interventions to be completed by the chaplain. There was no evidence of an ordered frequency for spiritual care visits.

Upon patient record review, 4 of 27 (Patients #1,#5,#13,#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 1: The medical record contained an order for Lumigan eye drops without instructions of whether to administer in both eyes or one eye. Patient 5: The medical record contained an order for Pepto-Bismol with no frequency, stating as needed without parameters for how often it can be administered. During home visit medication reconciliation, the daughter confirmed patient's dose of metoprolol is 12.5 mg daily, and takes prevastatin 40 mg daily. The medical record contained an order for metoprolol 25 mg daily, and did not have an order for prevastatin. Patient 13: The medical record contained an order for Voltaren topical gel with no area defined for administration. Patient 14: The medical record contained orders for a fluticasone inhaler with incorrect route via nasal cannula, and polyethylene glycol oral powder with no instructions to mix with a diluent.

Upon patient record review, 5 of 27 (Patients #3,#4,#5,#10,#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 equipment and supply needs. Patient 3: The medical record contained nursing documentation upon recertification assessment 2/3/26 identifying patient use of a fall pad. There was no evidence of an order for the DME included in the plan of care. Patient 4: The medical record contained nursing documentation upon recertification assessment 1/23/26 identifying patient use of a specialty mattress. There was no evidence of an order for the DME included in the plan of care. Patient 5: The medical record contained nursing documentation since admission identifying patient use of a shower chair. There was no evidence of an order for the DME included in the plan of care. Patient 10: The plan of care included an order for a nebulizer and there was no evidence of any orders for nebulized medication. Patient 14: The medical record contained nursing documentation upon recertification assessment identifying patient use of a hospital bed, full rails, walker, wheelchair, and nebulizer. There was no evidence of orders for the DME included in the plan of care.

Upon patient record review, 4 of 27 (Patients #3,#13,#15,#20) 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: The current plan of care contained former wound care interventions. There was no evidence the plan of care was updated to reflect the wound had been documented as healed 3/2/26. Patient 13: The medical record contained nursing documentation since recertification assessment identifying patient is a high risk for skin impairment requiring a specialty mattress. There was no evidence the plan of care was updated to include problems, goals, and interventions related to risk for skin breakdown. Patient 15: There was no evidence the plan of care was updated to omit problems, goals, and interventions to be completed by the chaplain. Spiritual care visits were ordered to be discontinued 3/5/26. Patient 20: There was no evidence the plan of care was updated to omit problems, goals, and interventions related to oxygen safety that were entered in error. The medical record did not contain an order for oxygen or documentation identifying patient use of oxygen.

Upon client record review, 2 of 27 (Patients #1,#18) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: The medical record contained an order for nursing visits twice weekly. There was no evidence of a second visit completed the week of 3/8/26. Patient 18: The medical record contained an order for nursing visits twice weekly. There was no evidence of a second visit completed the week of 3/1/26.

Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Patient 16: The medical record contained nursing documentation 3/21/26 identifying patient fell sustaining two black eyes and a bump on the temple. There was no evidence the incident was investigated and a plan of correction was developed to prevent similar events.

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 6: During observation of the RN, equipment used for vitals was placed on a barrier after use and was placed back onto the same area of the barrier after cleansing. There was no separation of clean and dirty sections maintained on the surface.

Upon patient record review, 1 of 27 (Patient #21) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 21: There was no evidence tasks were completed as assigned on the bereavement care plan.

Upon personnel record review, 1 of 17 (Personnel #8) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #8: No evidence of a competency assessment completed on all tasks.

Upon patient record review, 1 of 27 (Patient #3) did not have evidence in the patient record that hospice aide assignments and duties are specific to patient needs. Patient 3: The medical record contained nursing documentation identifying patient was a max assist with transfers since admission and use of a wheelchair since at least the recertification assessment 2/3/26. There was no evidence of instructions for transfer assistance and use of wheelchair on the aide care plan.

Upon patient record review 1 of 27 (Patient #11) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group Patient 11: The medical record contained an order for aide visits twice weekly. There was no evidence of second visits completed the weeks of 3/22/26 and 3/29/26.

Upon patient record review 1 of 27 (Patient #1) 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 1: There was no evidence of an aide supervisory visit completed between 3/5/26 and 4/3/26.

Upon patient client record review, 1 of 27 (Patient #2) 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 2: The medical record contained social worker documentation 4/7/26 stating a visit was missed due to patient death. Additional visits were completed by other disciplines to show evidence the documentation of death was in error.

Upon patient record review 2 of 27 records (Patient #4,#23) did not have evidence in the patient record that the comprehensive assessment identifies the spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's wellbeing, comfort, and dignity throughout the dying process. Patient #4: There was not evidence of a spiritual assessment. Patient #23: There was not evidence of a spiritual assessment.

Upon patient record review, 6 of 27 records (Patient #3,#6,#9,#15,#19,#20) 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 #3: The record indicated for an enema 19Gm- 7Gm/118ml, 1 prn per rectum prn impaction. There was not evidence of a frequency. In addition, the nurse documentation for the recertification note dated 5/3/23 indicated that the patient was on oxygen at 2L/min via nasal cannula. There was not evidence that this was in the medication profile. Corrected on site Patient #6: The record indicated that the patient was on oxygen 2-4L/min intermittently. There was not evidence of a route. Corrected on site. Patient #9: The record indicated for oxygen 2-4L/min continuous via nasal cannula. Upon observed home visit, the patient was not wearing oxygen and he stated that he only wears it at night. Corrected on site. Patient #15: The record indicated for oxygen continuous per instructions and the instructions were to wear oxygen prn via nasal cannula. There was not evidence of a liter flow. Corrected on site. Patient #19: The nurse admission documentation indicated that the patient was on oxygen 3-4L/min via nasal cannula. There was not evidence that this was added to the medication profile. Corrected on site. Patient #20: The record indicated Miralax 17GM powder packet daily prn. There was not evidence of a diluent. Corrected on site.

Upon patient record review, 4 of 27 records (Patient #1,#5,#20,#22) 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 #1: The patient was admitted on 2/3/23. The record indicated that the bereavement assessment was completed on 2/9/23. Patient #5: The patient was admitted on 1/6/22. The record indicated that the bereavement assessment was completed on 3/14/22. Patient #20: The patient was admitted on 12/21/22. The record indicated that the bereavement assessment was completed on 1/6/23. Patient #22: The patient was admitted on 1/27/23. The record indicated that the bereavement assessment was completed on 2/14/23.

Upon patient record review, 1 of 27 records (Patient #18) did not have evidence that a Registered Nurse ensured continuous assessment of the patient and family's needs and coordinated 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 #18: The patient was admitted with diagnosis of malignant neoplasm of the right breast nipple and areola. The admission documentation indicated that the patient had a fungating tumor. There was not evidence throughout the record of an assessment, description or visualization of this tumor.

Upon patient record review, 4 of 27 records (Patient #2,#10,#16,#20) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient that reflects 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 #2: The record indicated that a Foley catheter was inserted on 4/30/23. There was not evidence that the plan of care included information regarding interventions of the patient's progress towards outcome/goals. Corrected on site Patient #10: The patient was admitted with a hospice diagnosis of Parkinson's Disease. The patient's disease was progressing and she was not able to feed herself, her extremities were stiff and rigid, her feet were becoming deformed and her speech was declining. There was not evidence that the plan of care reflected patient/family goals and interventions related to her neurological problems, based on the initial, comprehensive, and updated comprehensive assessments. Corrected on site. Patient #16: The patient was admitted with a diagnosis of Alzheimer's Disease. There was not evidence of a care plan for neurological/Alzheimer disorders. Corrected on site. Patient #20: The patient was admitted with a diagnosis of Hemiplegia following cerebral infarct affecting the left non-dominant side. The patient also had a history of a traumatic brain injury, cognitive dysfunction, and chronic encephalitis. There was not evidence that the plan of care reflected patient/family goals and interventions based on the neurological problems identified in the initial, comprehensive, and updated comprehensive assessments. Corrected on site.

Upon patient record review, 3 of 27 records (Patient #1,#12,#20) did not have evidence that the plan of care 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 Patient #1: The visit frequency for the skilled nurse was 2x/week with 8 prns and the changed to 2x/week with 9 prns (effective at the second benefit period beginning 5/4/23). Corrected on site. Patient #12: The visit frequency for the skilled nurse for the benefit period beginning 3/19/23 was 2w9 and 8 prn. Corrected on site. Patient #20: The visit frequency for the skilled nurse was 2/week with 7 prns. Corrected on site.

Upon patient record review, 6 of 27 records (Patient #3,#6,#9,#15,#19,#20) 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 #3: The record indicated for an enema 19Gm- 7Gm/118ml, 1 prn per rectum prn impaction. There was not evidence of a frequency. In addition, the nurse documentation for the recertification note dated 5/3/23 indicated that the patient was on oxygen at 2L/min via nasal cannula. There was not evidence of an order. Corrected on site. Patient #6: The record indicated that the patient was on oxygen 2-4L/min intermittently. There was not evidence of a route. Corrected on site, Patient #9: The order indicated for oxygen 2-4L/min continuous via nasal cannula. Upon observed home visit, the patient was not wearing oxygen and he stated that he only wears it at night. Corrected on site. In addition, the record contained an order dated 4/11/23 for urinary retention to straight catharize with a #14 Fr 'now and prn.' There was not evidence of a specific prn frequency. Corrected on site. Patient #15: The record indicated for oxygen continuous per instructions and the instructions were to wear oxygen prn via nasal cannula. There was not evidence of a liter flow. Corrected on site. Patient #19: The nurse admission documentation indicated that the patient was on oxygen 3-4L/min via nasal cannula. There was not evidence of an order. Corrected on site. Patient #20: The record indicated Miralax 17GM powder packet daily prn. There was not evidence of a diluent. Corrected on site.

Upon client record review, 3 of 27 records (Patient #2,#14,#16) 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 skilled nurse frequency was 3w13 on admission. On 3/31/23 changed to 2x/week, on 4/27/23 changed to 3x/week and on 4/30/23 was 6w1, 9w1, 3w1, 2w3, 1w1. There was not evidence that these frequencies were followed as the agency was attempting to meet the rapidly changing needs of the patient; the agency confirmed they did not follow the ordered visit frequencies. Corrected on site. In addition, the social worker visit frequency was 1m1, 2m2. The patient was admitted on 3/15/23. There was not evidence of a second visit by the social worker for the month of April. Patient #14: The visit frequency for the volunteer was to provide companionship 1x/week effective 3/15/23. There was not evidence of a visit by the volunteer. Corrected on site. Patient #16: The visit frequency for the spiritual care counselor for the benefit period of 3/10/23-5/8/23 was 4m1, 6m1, 3m1. The record indicated visits on 3/22/23, 4/5/23, 4/19/23, and 5/4/23 which is not in compliance with the ordered frequency. Corrected on site.

Upon patient record review, 1 of 27 records (Patient #1) 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 #1: The nurse documentation dated 4/6/23 and 4/10/23 indicated that the environment where the patient resided, had bed bugs. There was not evidence in the record that this finding/information was shared and coordinated with the IDG. Corrected on site.

Upon patient record review, 3 of 27 records (Patient #1,#3,#12) 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 specific patient care instructions, including alerts and precautions, for a hospice aide that 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 Patient #1: The nurse documentation dated 4/6/23 and 4/10/23 indicated that the environment where the patient resided, had bed bugs. There was not evidence of precautions for bed bugs in the aide plan of care. Corrected on site. Patient #3: The certification of terminal illness indicated that the patient had frequent falls. There was not evidence of fall precautions on the aide plan of care. Corrected on site. Patient #12: The record indicated that the patient had frequent falls and on 9/16/22, just prior to admission to hospice, she had a fall and sustained a closed head injury, which resulted in a trip to the Emergency Department. There was not evidence of fall precautions on the aide plan of care. Corrected on site.

Upon patient record review 1 of 27 records (Patient #8) 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 Patient #8: The aide visit frequency was 3x/week. For the weeks of 3/26/23-4/29/23, the record indicated only 2 visits each week with no evidence of missed visit documentation. Corrected on site.

Upon client record review, 1 of 27 records (Patient #20) 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 #20:The volunteer visit frequency was for 1x/week for companionship. For the week of 4/2/23- 4/8/23, the record indicated 2 visits and for the week of 4/9/23-4/15/23, there was not evidence of a visit by the volunteer. Corrected on site.