Every finding on record at Crown Hospice, Inc.

Upon patient record review 3 of 14 (Patient #1, #7, #10) 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 #1: The record indicated the patient was admitted on 03/28/25, there was no spiritual comprehensive assessment completed at the time of the survey. Patient #7: The record indicated the patient was admitted on 08/14/25, there was no spiritual comprehensive assessment completed at the time of the survey. Patient #10: The record indicated the patient was admitted on 02/21/25, there was psychosocial comprehensive assessment completed at the time of the survey.

Upon patient record review, 10 of 14 charts reviewed (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10) 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, #2, #3, #4, #5, #6, #7, #8, #9, #10: The record indicated there were medication reviews during all IDG meetings, there was no review of the effectiveness of drug therapy. Patient #2: The record indicated the patient was to use Thick It 5gm 1 powder oral as needed, there was no indication listed. COS. Patient #4: The record indicated the patient had an order for Senna 8/6mg one tab po daily at night for constipation on 07/23/25, during the IDG meeting on 07/31/25 there was no review for effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy and or drug therapy currently associated with laboratory monitoring. This review was left blank. Patient #9: The record indicated the patient had an order for Oxygen 2-5 LPM via NC as needed for shortness of breath and dyspnea, this was not listed on the medication profile. COS.

Upon patient record review, 2 of 14 records reviewed (Patient #1, #7) 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 record indicated the patient was admitted on 03/28/25, there was no initial bereavement assessment completed within 5 days at the time of the survey. Patient #7: The record indicated the patient was admitted on 08/14/25, there was no initial bereavement assessment completed within 5 days at the time of the survey.

Upon patient record review, 10 of 14 charts reviewed (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10) 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, #2, #3, #4, #5, #6, #7, #8, #9, #10: The record indicated the RN was making monthly visits, there was no assessment update at a minimum of every 15 days.

Upon patient record review, 2 of 14 records reviewed (Patient #1, #3) 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 #1: The patient had a pain level of 8 out 10 and moderate shortness of breath with an O2 saturation level of 92% on room air on 03/28/25 there was no RN continuous assessment until 03/30/25. Patient #3: The patient had a pain level of "5" and was noted to be irritable and crying on 07/12/25, the pain care plan goal was "0-2", there was no RN continuous assessment follow up until 07/19/25.

Upon patient record review, 3 of 14 records reviewed (Patient #1, #2, #4) 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 #1: The record indicated the patient was a full code at the time of hospice admission, there was no individualized written plan of care reflecting the patient/family goals and interventions based on this problem. In addition, the intervention for the pain was stated to use PAINAD, the patient had no history of Dementia and could rate the pain using a 1-10 pain scale. both COS. Patient #2: The record indicated the patient was a full code and had no mortuary listed at the time of hospice admission, there was no individualized written plan of care reflecting the patient/family goals and interventions based on this problem. COS. Patient #4: The record indicated the patient was a full code at the time of hospice admission, there was no individualized written plan of care reflecting the patient/family goals and interventions based on this problem. COS.

Upon patient record review, 4 of 14 records reviewed (Patient #1, #2, #3, #4) 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 #1: The record indicated an initial evaluation order for the social worker, there was no scope and frequency orders for the patient at the time of the survey. COS. Patient #2: The record indicated an initial evaluation order for the social worker, there was no scope and frequency orders for the patient at the time of the survey. COS. Patient #3: The record indicated an initial evaluation order for the social worker and chaplain, there was no scope and frequency orders for the patient at the time of the survey. COS. Patient #4: The record indicated an initial evaluation order for the social worker, there was no scope and frequency order for the patient at the time of the survey. COS.

Upon patient record review, 1 of 14 records reviewed (Patient #2) 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 record indicated an order for Thick It 5gm 1 powder oral as needed but had not indication. In addition, there was no order for the specific amount and or frequency for the ensure. both COS.

Upon patient record review, 2 of 14 records reviewed (Patient #1, #3) 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 record indicated the patient was using a cane and was incontinent of bladder requiring incontinent supplies, there was no DME and or supplies listed in the plan of care. COS. Patient #3: The record indicated the patient had an oxygen concentrator, this was not listed on plan of care. COS.

Upon observation, there was no evidence in the QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. There was no evidence in the QAPI reports for the surveillance to include employee infection tracking.

Upon patient record review 1 of 14 record reviewed (Patient #2) 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 #2: The record indicated a RN made a supervisory visit on 04/20/25 and the next supervisory was due on 05/04/25 and was not completed. In addition the record indicated a RN made a supervisory visit on 05/08/25, the next supervisory due was on 05/22/25 and was not completed until 05/23/25.

Upon personnel record review, 1 of 15 Records Reviewed (Personnel #9) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #9: The record did not include a skills competency assessment for the Speech Therapists. COS.