Every finding on record at Destiny Hospice Care, Inc.

Observed in Record Review. In 2 of 14 patient records reviewed, During HOSRR#2 it was noted the initial RN evaluation did not include an assessment of the patient's diabetic status that was documented as a comorbidity with 2 types of insulins prescribed. In addition, the patient was treated in a hospital ER for a chemical burn of his eyes caused by a ruptured battery and returned home with bandages to his eyes as documented in a communication note in March 2025. There was lack of an SN assessment of the injury post ER visit. During HOSHV#3 it was noted lack of an assessment of the patient's diabetic status during the initial RN evaluation with glipizide and Jardiance prescribed. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 14 patient records reviewed, During HOSRR#2 it was noted the middle of April 2025, a physician order for Bactrim and Pyridium x 3days to treat the patient's UTI, however, during the IDG meeting 5 days later the RN summary lacked documentation of the UTI. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 14 patient records reviewed, During HOSRR#5 it was noted the patient had a pressure ulcer on the right buttock. The interventions for wound care on the POC listed a different body part and treatment order than the pressure ulcer wound care order in the POC summary. The POC lacked the accurate documentation of the location and treatment for wound care. The documentation was corrected during the survey. This was discussed with the organization leadership.

Observed in Record Review. In 6 of 14 patient records reviewed, During HOSRR#1 the RN, during the initial evaluation, documented the patient's secondary diagnosis was cachexia, dysphagia and abnormal weight loss, however, the POC lacked nutritional assessment and interventions. The patient had a new order for oxygen therapy and nebulizer treatments as needed for SOB. The POC lacked interventions on use and safety of oxygen therapy and use of the nebulizer. The patient was assessed by the RN during the initial visit to have a high risk for skin breakdown identified on the Braden assessment however there were no interventions on the POC related to prevention of skin breakdown. During HOSRR#2 it was noted the patient developed a UTI, however the POC lacked assessment of the GU status and interventions related to the patient's UTI. During HOSRR#2 it was noted the patient was admitted to a hospital emergency department after a bilateral eye chemical burn in March 2025 and returned home with ointment and cream and instructions to keep eye covered per communication log documentation. There was lack of an update to the POC for assessment, treatment and interventions related to the chemical burn. During HOSHV#4 it was noted a circulatory deficit on the POC however there were no interventions documented. During RR#4 it was noted a deficit of anxiety on the POC with the following goal: pt/pcg will be able to manage anxiety with interventions in place within the next IDG meeting however the POC lacked interventions with only assessments documented to accomplish the goal. During HOSRR#9 it was noted the patient had a UTI with antibiotics prescribed. The POC lacked interventions related to assessment of the UTI, instruction on perineal care, hydration, and s/s UTI. During HOSRR#8 it was noted in April 2025 during an IDG meeting, the RN documented a stage 1 pressure area to the patient's left elbow. The POC was not updated to include interventions for the newly identified left elbow pressure area. This was discussed with the organization leadership.

Observed in Record Review. In 2 of 14 patient records reviewed, During HOSHV#1 it was noted the frequency of visits for SN, MSW and SC had PRN visits ordered without documentation of the reasons for the additional visits if needed. During HOSHV#3 it was noted PRN visits for the SN and MSW without documentation of the reasons for the as needed visits. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 14 patient records reviewed, During HOSRR#4 it was noted on the POC an intervention under an endocrine deficit to monitor for hyperglycemia. There was lack of documentation that hyperglycemia s/s were assessed on 6 SN notes to date after the initial RN evaluation. This was discussed with the organization leadership.

Based on observation, interview, and record review, the agency failed to ensure the medications listed in the patient's current medication profile and the Plan of Care (POC) were updated, accurate, and complete for one of four patients reviewed (Patient 7) when: Two medications Acarbose (a medication used for diabetes- a condition when there is too much sugar in the blood) 25 milligram (mg - a unit of measurement) one tablet oral (by mouth) three times a day, and Singulair (medication used to prevent asthma and breathing problem) 10 mg one tablet oral daily were not available for use and were still listed in Patient 7's current POC and current medication profile; Two medications Thera Tears eye drop for extra dry eye therapy and Safe Tussin DM (for cough and congestion) were available for use but the medications were not listed in Patient 7's current POC and medication Profile. This failure had the potential for Patient 7's primary caregiver (PCG) and the agency not to be able to identify the significant side effects, drug interactions, duplicate drug therapy, and patient's noncompliance with prescribed medications and administration of medications not currently prescribed by the physician. --- Findings: On October 9, 2024, Patient 7's record was reviewed. Patient 7 was admitted to the agency with the Start of Care (SOC) date of September 20, 2024, with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD - a lung disease). The physician Certification of Terminal Illness (CTI) for the certification period from September 20, 2024 to December 18, 2024, indicated Patient 7 was dependent on oxygen at three liters per minute through nasal cannula (a small tube that provides oxygen with two prongs through the nose). Patient 7 had a weight loss of eight to 10 pounds within two months, poor mentation, and short of breath on exertion. The POC/IDG (Interdisciplinary Group - a team responsible for the care of the patient) dated September 20, 2024 and October 2, 2024, indicated Patient 7 was on medications Acarbose 25 mg one tablet three times a day, and Singulair 10 mg one tablet oral daily. The frequency of Skilled Nurse (SN) visit indicated two times a week and three visits as needed. On October 10, 2024, at 9 a.m., a home visit was conducted with the Licensed Vocational Nurse (LVN) for Patient 7. Patient 7's PCG was present during the visit. Patient 7 was observed awake, lying in bed with oxygen on at three liters per minute through nasal cannula. Patient 7 was verbally responsive in short words. The PCG/DPOC (Durable Power of Attorney - a person who was given the power to make decisions on behalf of the patient) signed the consent for the home visit. On October 10, 2024, at 9:53 a.m., a concurrent interview and medication review was conducted with the LVN and the PCG. The PCG stated she managed and administered Patient 7's daily medications. During the medication reconciliation (a process of comparing a patient's current medications to the medication orders to identify and resolve discrepancies) the following were observed: - The two medications Acarbose 25 mg one tablet oral 3x a day and Singulair 10 mg tablet oral one tablet daily were not available for use. The medications were listed in Patient 7's current medication profile and current POC; and The PCG stated the two medications had been discontinued by Patient 7's primary care physician prior to the SOC. - The two medications Thera Tears eye drop and Safe Tussin DM were available for use but the medications were not listed in Patient 7's current medication profile and current POC. The PCG stated the medication Thera eye drops had been prescribed by Patient 7's primary care physician since last year. She stated she had been giving Patient 7 the Thera eye drops one eye drop to each eye every three to four hours as needed for dry eyes. The PCG stated the medication Safe Tussin for cough and congestion was bought over the counter. She had been giving Patient 7 two table spoon every four hours as needed for her cough. The LVN stated she was not aware the medications Acarbose and Singulair were discontinued and were not available. She stated she did not know Patient 7 was using the Thera Tears eye drop and the Safe Tussin cough syrup as needed. She stated she had not conducted the medication reconciliation during her visits on October 1, 2024 and October 3, 2024. The LVN acknowledged the medications Acarbose and Singulair were still listed in Patient 7's current medication profile and current POC. She stated the medications Thera Tears eye drop and the Safe Tussin cougn syrup should have been listed in Patient 7's current medication profile and current POC. On October 11, 2024, at 1:30 p.m., the Clinical Coordinator was interviewed. She stated the licensed nurses should have conducted the medication reconciliation on every visit for Patient 7. A review of the agency's policy and procedure tilled, "Comprehensive Assessment," dated October 2014, indicated,"...A comprehensive patient assessment will be performed by the hospice IDG...in consultation with attending physician...During the comprehensive assessment relevant information will be documented...Review of current and related past medications, including prescription and over-the-counter medications..." A review of the agency's policy and procedure titled, "Medication Monitoring," dated October 2014, indicated, "...Ongoing patient medication monitoring will be use a collaborative approach among the clinicians, physicians, pharmacist, and patients and family/caregivers...Evaluate the continued use of a medication in the current regimen, evaluate patient adherence to the prescribed medication..."

Observed in Record Review. In 2 of 2 patient records reviewed, during record review for HOSV#3, HOSRR#2 , the hospice surveyor noted that wound care assessment was being completed every visit but the wound size was not being documented as per the organization policy section 4.24 wound cleansing section No 6 observe for : wound size , including length , width, and depth. this was confirmed by the Nurse Administrator.

Observed in Record Review. In 6 of 6 patient records reviewed, during records reviewed, of HOSV# 1-3 and HOSRR#1, 2,3 there were no measurable out comes included in the plans of care for any of the identified goal. for example in HOSRR#2 : PCG will be able to speak to managed feelings of grief/loss, -Pt/ Family/PCG will verbalize receiving desired spiritual support for strengthening of personal faith.. This was confirmed with the Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, It was noted in HOSV#3, there was an incomplete order for wound care. The order read: May cleanse coccyx wound with saline pat dry apply flagyl powder to coccyx wound with gauze x2 daily, cover with clean dry dressing, change as needed for dislodgment and or soiling, continue to monitor for sign and symptoms of infection. The order did not specify the person who will providing the wound care. This finding was validate with COO.

Observed in Record Review. In 3 of 13 patient records reviewed, for HOSRR#1, 3 and HOSV #3 the Hospice interdisciplinary care plan did not comprehensively reflect measurable goals associated with identified problems not in the patient assessment. For example based on a review of the nursing assessment of HOSRR#1 the following issue was identified; Upper Respiratory Infection In HOSV#3 the issue identified: Vomiting. The care plan did not identified the problem, goals or outcomes to be achieved anticipated from interventions. This observation was confirmed with the nurse Administrator

Observed in Patient Home. In 1 of 3 home visits conducted, During HOSV#3 the nurse surveyor noted that the wound was not provided according to the plan of care. The order read: May cleanse coccyx wound with saline pat dry apply flagyl powder to coccyx wound with gauze x2 daily, cover with clean dry dressing, change as needed for dislodgment and or soiling, continue to monitor for sign and symptoms of infection. It was observed that the nurse cover the wound with a wet dressing instead of a dry dressing. This was also observed by the Nurse Executive Assistant.

Observed in Patient Home. In 1 of 3 home visits conducted, The organization failed to implements its infection prevention and control activities. It was observed during HOSV#3 that the nurse did not consistently follow the organizational policy Hand Hygiene policy # 9-006. The hospice surveyor noted that the Nurse failed to change gloves during wound care. The nurse kept the same pair of glove to wash and dress the wound during wound care . This was validated with Nurse Executive Assistant.