Every finding on record at Crescent Hospice, Inc.

Upon patient record review, 1 of 28 (Patient #17) 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 #17: Medication profile reflects incomplete order 4/7/26 Lorazepam 1 mg oral tablet, take 1 tab(s) orally as needed for anxiety or restlessness. Frequency of dose not specified.

Upon patient record review, 1 of 28 (Patient #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 #17: Upon review, surveyor noted 4/27/26 order for Lorazepam 0.5 mg oral tab one tab orally 2 times a day for anxiety. There is also a 4/7/26 order for 1 mg oral tab as needed. 4/28/26 on call nurse documented that facility staff called to report during 1-pm rounding, patient was on the phone with 911, seeing people in the room that were not there and anxious. She reported the facility didn't give any of the scheduled Lorazepam today due to being out. Facility nurse reported that they only have the prn dose of Lorazepam in their med cart. (Hospice nurse) instructed to give dose of PRN Lorazepam per orders and to see if that dose relieves symptoms. Instructed to call on-call number back if ineffective or other concerns arise. Verbalizes understanding. 2 days later, another PRN visit 4/30/26 related to patient agitation. RN documented educated staff related to Ativan, but regular dose has not come in. No additional documentation of follow up or resolution by date of record review.

Upon patient record review, 2 of 28 (Patient #2, 8) 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 #2: Patient admitted with pacemaker. There are no related problems, goals, interventions. Patient #8: Patient has documented seizure disorder according to CTI and diagnoses; however, there are no related problems, goals, interventions including seizure safety precautions.

Upon patient record review, 2 of 28 (Patient #1, 17) 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: Wound care order to clean mid upper and mid left friction pannus wound daily and PRN with wound cleanser, pat dry with gauze and place bordered dressing. PRN is not qualified Patient #17: 4/7/26 order for Lorazepam 1 mg oral tablet, take 1 tab(s) orally # as needed for anxiety or restlessness. Frequency of dose not specified.

Upon patient record review, 1 of 28 (Patient #28) 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 #28: SN visit 4/29/26 RN noted skin lesion of scalp - large necrotic area on head - continue to monitor. Upon observation during visit and interview with RN, the lesion is expected to be skin cancer and family chose no further diagnostics or treatments. The lesion is changing in size and appearance. The care plan is not updated with problems, goals or interventions related to at a minimum to assess for discomfort and alteration in skin integrity.

Upon client record review, 2 of 28 (Patient #3, 4, ) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: Volunteer 9 m1m effective 4/1/26-4/30/26. Visits documented April 2, 8, 12, 22/26 Patient #4: Volunteer 4m1m effective 4/1/26 -4/30/26. Only documented visits are 4/2 and 4/7/26

Upon patient record review, 3 of 28 (Patient #2, 5, 19) 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 #2, 5: Oxygen is prescribed, but hospice aide care plan does not include Oxygen safety precautions. Patient #19: Patient admitted with urostomy. There is no alert, precaution or reference of any kind to urinary diversion included in hospice aide care plan.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Upon observation and interview, the 2025 annual review does not equal 5 percent. 1.12% is the aggregate volunteer cost savings for all locations.

Upon client record review, 2 of 28 (Patient #21, 22) did not have evidence that the discharge summary includes all required information. Patient #21: Patient transferred to ER per daughter's choice. DC Summary does not include current plan of care, orders - including medications, Oxygen and/or history of thoracentesis. Patient #22: Patient transferred to non-contracted hospital. DC Summary does not include current plan of care other than medications and diagnoses. No reference to heel wound.

Upon client record review, 3 of 28 (Patient #1, 8, 15) 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: Patient has orders for wound care to abdominal pannus with no clarification of facility staff vs hospice role. Patient #8: Patient has order for wound care to right heel with no clarification of facility staff vs hospice role for PRN wound care between hospice visits. Admitted with indwelling foley catheter in place. Order says change as ordered, every 30 days, without clarification of facility/hospice staff role in maintaining catheter and/or changes. Subsequently catheter was discontinued by facility staff with no prior coordination with hospice. Patient #15: SNF resident with wound care order 3/20/26 for skin tears x 2 right forearm, without clarification of facility staff vs hospice role for wound care

Upon patient record review 1 of 27 (Patient #24) 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 24 The patient was admitted on 11/29/22, the patient refused spiritual care services, a spiritual care assessment was not completed by the RN or MSW at the time of admit. The patient received a spiritual care assessment on 1/17/23.

Upon patient record review 3 of 27 (Patient 12, 26, 27) 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 12 The patient was admitted on 3/1/23, the record does not contain a spiritual care assessment upon admit or to date. Patient 26 The patient was admitted on 5/24/23, the record does not include a spiritual care assessment upon admit or to date. Patient 27 The patient was admitted on 2/10/23, the record does not contain a psychosocial assessment upon admit or to date.

Upon patient record review, 7 of 27 (Patient #1, 2, 12, 13, 14, 17, 18) 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 patient had orders initiated on 3/22/23 for Acyclovir 400 mg 1 pill every 8 hours via G-tube x 10 days, this remains on the medication profile at this time. Medication profile includes Voltaren Gel 1% initiated on 3/22/23 and does not include an application site. Medication profile includes Glycopyrrolate 5 ML as needed, does not include and indication for use. (All corrections completed on site.) Patient 2 Medication profile includes Miralax 17g PO daily, does not include a diluent for mixing. During the home visit, medication review included Isosorbide Dinitrate 30 mg oral BID, Carvedilol 6.25mg oral BID and Plavix 75 mg oral one tablet daily ordered on 5/19/23 that are not included in the hospice medication profile. Patient 12 Medication profile includes Clortrimazole Cream 1% does not include an application site. (Corrected on site) Patient 13 Medication profile includes Refresh Tears Opthalmic Solution 0.5% give 1 drop PRN every 8 hours OP, does not include and indication for use, or specify which eye to instill in. (Corrected on site.) Patient 14 The medication profile includes Polyethylene Glycol 3350 powder, does not include a diluent for mixing. (Corrected on site.) Patient 17 The medication profile includes Polyethylene Glycol 3350 powder 1 packet as needed PO, does not include a diluent for mixing and does not include an indicator for use. Medication profile includes Ativan 0.5mg 1 tablet as needed, does not have an indicator for use. Medication profile includes acetaminophen 325mg 2 tablets every 8 hrs PRN, does not include an indicator. (Corrected on site.) Patient 18 The medication profile includes hydroxyzine 25mg PO as needed, does not include an indicator for use. Medication profile includes Miralax powder 17g PO daily, does not include a mixing diluent. Medication profile includes Albuterol HFA inhaler 2 puff PRN every 4 hours does not include an indicator for use. (Corrected on site.)

Upon patient record review, 2 of 27 (Patient 15, 27) 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 15 The initial comprehensive assessment on 5/4/23 indicates the patient has a diagnosis of liver cirrhosis with ascites, the initial plan of care does not include a problem statement with goals or interventions for the management of the ascites. (Corrected on site, added to the current plan of care.) Patient 27 The initial comprehensive assessment on 2/10/23 identifies issues for patient safety and nutritional deficits/needs. The initial plan of care does not include a problem statement with goals and interventions for the management of the nutritional status or the safety of the patient. (Corrected on site, added to the current plan of care.)

Upon patient record review, 7 of 27 (Patient 1, 2, 12, 13, 14, 17, 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 1 Medication orders initiated on 3/22/23 for Acyclovir were to be implemented x 10 days. The medication remains listed on the medication profile at this time. Orders for Voltaren Gel 1% initiated on 3/22/23 do not indicate an application site. Orders on 12/29/22 for Glycopyrrolate 5 ML as needed, do not include an indication for use. (Corrected on site.) Patient 2 Medication orders on 6/21/21 for Miralax 17g PO daily, do not include a diluent for mixing. During the home visit, medication review included medication ordered on 5/14/23 for Isosorbide Dinitrate 30 mg oral BID, Carvedilol 6.25mg oral BID and Plavix 75 mg oral one tablet daily ordered on 5/19/23 that are not included in the hospice medication profile/orders. (Corrected on site.) Patient 12 Medication orders on 6/5/23 for Clortrimazole Cream 1% do not include an application site. (Corrected on site) Patient 13 Medication orders for Refresh Tears Opthalmic Solution 0.5% give 1 drop PRN every 8 hours OP, does not include an indication for PRN use, or specify which eye to instill in. (Corrected on site.) Patient 14 The medication orders on 4/7/23 for Polyethylene Glycol 3350 powder, do not include a diluent for mixing. (Corrected on site) Patient 17 The medication orders on 3/21/23 for Polyethylene Glycol 3350 powder 1 packet as needed PO, do not include a diluent for mixing and does not include an indicator for "as needed" use. Orders on 3/21/23 for Ativan 0.5mg 1 tablet as needed, does not have an indicator for "as needed" use. Orders on 3/21/23 for acetaminophen 325mg 2 tablets every 8 hrs PRN, do not include an indicator for PRN use. (Corrected on site.) Patient 18 The medication order on 3/30/23 for hydroxyzine 25mg PO as needed, does not include an indicator for PRN use. Orders on 2/1/23 for Miralax powder 17g PO daily, do not include a mixing diluent. Orders on 12/30/22 for Albuterol HFA inhaler 2 puff PRN every 4 hours do not include an indicator for PRN use. (Corrected on site)

Upon patient record review, 3 of 27 (Patient #1, 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 equipment and supply needs. Patient 1 The patient is incontinent of bladder and bowel and requires incontinent supplies, these are not included in the plan of care. (Corrected on site) Patient 16 The patient is incontinent of bladder and bowel as documented on 12/9/23 by the visiting RN, the incontinent supplies are not included in the plan of care. The patient utilizes an "electric hospital bed" as documented on 12/8/23 by the SCC, the bed is not listed in the plan of care. Patient 18 The patient record indicates that the patient has bladder incontinence and requests the use of bladder pads, this is not included in the plan of care (Corrected on site.)

Upon patient record review, 4 of 27 (Patient #1, 15, 16, 17) 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 interventions included in the plan of care for the management of the gastrostomy tube do not align with the goals listed. (Ex: The enteral feeding tube will remain patent. Interventions: assess the skin integrity around the stoma at each visit.) (Corrected on site.) Patient 15 The plan of care includes hospice aide tasks effective 5/16/23, there are no orders for hospice aide services in the plan of care. (Corrected on site.) Patient 16 The nursing documentation on 12/02/22 indicates a request by family members to discontinue some of the patient medications due to the patient not taking them and sleeping 20-22 hrs per day. The medication profile was not updated to discontinue any of the patient medications. In the documentation by the RN on 12/29/22, the nurse is aware of patient decline and approaching death, the plan of care was not updated to include interventions and goals for the management of the EOL needs. Patient 17 The nursing documentation on 6/6/23 indicates ongoing decrease in patient MAC from 27cm to 24 cm, the plan of care does not include a problem statement with interventions and goals for the nutritional status/needs of the patient. (Corrected on site)

Upon client record review, 6 of 27 (Patient #1, 2, 9, 12, 13, 27) 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 patient orders for spiritual care are 2x month effective 2/1/23. The patient records indicates the patient received spiritual care visits on 2/23/23, 3/7/23, and 5/26/23, there are no visits for the month of April. The patient orders for MSW services is 2 x month effective 2/1/23, the record does not indicate any MSW visits for the month of April 2023 and the patient received only 1 visit in the month of May. Patient 2 Oxygen orders on 8/24/21 are written for Oxygen 4L per minute, the nursing documentation from 1/13/23 to 6/2/23 indicates that the patient was receiving O2 5 LPM, there is no evidence in the patient record of orders to increase the oxygen flow. (Corrected on site.) Patient 9 Review of clinical record revealed the visit frequency for the Medical Social Worker (MSW) was 1 x month, a visit was not made by the MSW during the month of May. A SN was assigned to visit the patient 1 x week and PRN. A visit was not made during the week of 4/2/23. An aide was assigned to provide personal care services 1x week, an aide visit was not made during the week of 4/14/23. Patient 12 The patient received a PRN visit for placement needs from the SW on 5/16/23, there are no orders for scheduled or PRN visits for SW services in the plan of care. Patient 13 The plan of care includes orders for spiritual care 1x per month effective 3/8/23, the patient did not receive a SC visit for the month of April. Patient 27 The patient record indicates orders for HHA services to start on 2/12/23 for 2x wk, there was one visit made during week 1, there were no visits made for week 2 and one missed visit for week 3, visits were made on 2/17, 2/23 and 3/3. Missed visits were documented on 3/31, 4/7, 5/12 and 5/26.

Upon patient record review, 2 of 27 (Patient #13, 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 13 The aide task assignment for bathing is indicated as shower or bed bath "per patient decision." (Corrected on site) Patient 14 The aide task assignment for "complete bed bath" does not include a frequency. (Corrected on site.)

Upon patient record review, 1 of 27 (Patient #4) did not have evidence that the hospice assumes responsibility for professional management of the resident's hospice services in accordance with the hospice plan of care. The hospice is responsible for providing all hospice services including: • Ongoing assessment, care planning, monitoring, coordination and provision of care by the Hospice IDG • Assessment, coordination and provision of any needed general inpatient or continuous care • Consultation about the patient's care with facility staff • Coordination by the hospice RN for the implementation of the plan of care for the patient • Provision of hospice aide services, if these services are determined necessary by the IDG to supplement the nurse aide services provided by the facility • Provision, in a timely manner, of all supplies, medications, and DME needed for the palliation and management of the terminal illness and related conditions • Financial management responsibility for all medical supplies, appliances, medications and biologicals related to the terminal illness and related conditions • Determination of the appropriate level of care to be given to the patient (routine homecare, inpatient, or continuous care) • Arranging any necessary transfers from the facility, in consultation with the facility personnel Patient #4 Upon admission on 1/3/23, the patient has an identified Stage IV sacral wound. Physician's order dated 1/3/23 indicated RN to coordinate wound care with facility staff. The patient record review revealed the hospice RN failed to assign and coordinate the wound care with the facility staff. There is no evidence in the record that the hospice nurse has performed the ongoing assessment of the wound or provided wound care to the patient. Review of the hospice plan of care lacked evidence of coordination of care between the hospice and the facility.

Upon client record review, 3 of 27 (Patient #4, 14, 16) 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 4 The patient record does not identify the care and services that are to be provided to the patient or the delegation of responsibility between the hospice and the nursing facility. Patient 14 The patient record does not identify the care and services that are to be provided to the patient or the delegation of responsibility between the hospice and the nursing facility. Patient 16 The patient record does not identify the care and services that are to be provided to the patient or the delegation of responsibility between the hospice and the nursing facility.