Every finding on record at Divinity Hospice, LLC

Upon patient record review 1 of 14 (Patient #2) 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 #2 - The patient medical record showed an admission date of 01/03/26. The psychosocial assessment was not completed until 01/11/26.

Upon patient record review, 1 of 14 (Patient #7) 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 #7 - The medication profile contained Miralax 17 gm daily for constipation. There was no evidence that a diluent was added to the instructions.

Upon patient record review, 8 of 14 (Patient #1,2,3,4,5,6,8,9) 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 #1 - The medication profile contained Narcan 4mg/0.1ml 1 spray via nostril for increased agitation from opioid. There was no evidence of problems, goals, or interventions listed. Patient #2 - The medication profile contained aspirin 81 mg daily for clot prevention. There was no evidence of problems, goals, or interventions related to the bleeding risk of that medication. Patient #3 - The medical record contained an order for a pureed diet. There was no evidence of problems, goals, or interventions related to dysphagia. Patient #4 - The medication profile contained Narcan 4mg/0.1ml 1 spray via nostril for increased agitation from opioid. There was no evidence of problems, goals, or interventions listed. The medication profile also included aspirin 81 mg daily for clot preventions. There was no evidence of problems, goals, or interventions related to the bleeding risk of that medication. Patient #5 - The medication profile contained aspirin 81 mg daily for clot prevention. There was no evidence of problems, goals, or interventions related to the bleeding risk of that medication. All nursing assessment list patient diet as pureed. There was no evidence of problems, goals, or interventions related dysphagia. Patient #6 - The medication profile contained Narcan 4mg/0.1ml 1 spray via nostril for increased agitation from opioid. There was no evidence of problems, goals, or interventions listed. Patient #8 - The medication profile contained aspirin 81 mg daily for clot prevention. There was no evidence of problems, goals, or interventions related to the bleeding risk of that medication. Patient #9 - The medication profile contained Narcan 4mg/0.1ml 1 spray via nostril for increased agitation from opioid. There was no evidence of problems, goals, or interventions listed.

Upon patient record review, 1 of 14 (Patient #7) 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 #7 - The medical record contained an order for MiraLAX 17 gm daily for constipation. The order did not contain a diluent.

Upon patient record review, 7 of 14 (Patient #3,4,5,6,8,9,10) 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 RN comprehensive assessment noted patient was incontinent of bowel and bladder. There was no evidence of incontinent supplies listed on patient's plan of care. Patient #4 - The RN recertification visit dated 03/02/26 and subsequent visits contained documentation that patient was incontinent of bowel and bladder. There was no evidence that incontinent supplies were added to the patient's plan of care. Patient #5 - The registered nurse assessments document patient is incontinent of bowel and bladder. There was no evidence that incontinent supplies were added to the patient's plan of care. Patient #6 - The nurse recertification visit dated 02/07/26 indicated patient had a stage 1 pressure ulcer to the sacrum area and was being treated with a collagen sheet and NA gel and to cover with a gauze. There was no evidence that these wound care supplies were listed on the patient's plan of care. Patient #8 - The recertification nurse visit and subsequent visits documented that patient was incontinent of bowel and bladder. There was no evidence of incontinent supplies listed on the patient's plan of care. Patient #9, 10 - The nursing notes indicated patient is incontinent of bowel and bladder. There was no evidence of incontinent supplies listed on the patient's plan of care.

Upon client record review, 1 of 14 (Patient #6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #6 - The RN recertification visit dated 02/07/26, included documentation of wound care to the stage 1 sacrum area. The documentation included the need to add a collagen sheet with NA gel and cover with gauze. The medical record did not include an order for this wound care.

Upon client record review, 1 of 14 (Patient #5) 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 #5 - While completing the home visit with the aide, noted the facility nurse came to suction patient multiple times during care. The hospice medical record did not contain an order to complete that task.

Upon patient record review, 1 of 14 (Patient #1) 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: Upon admission, patient medications include Glucotrol 10 mg, (dose 2 tabs), but 1 tab am, 1 tab lunch, 1 tab HS. The medication profile is unclear. Furthermore, 3/23/23 SN visit documents that patient reported MD visit 3/20/23 and Glipizide was adjusted to 5 mg po in mornings. This medication profile is unclear as to whether lunch and HS tabs are continued. The adjustment was made related to evening incidents of hypoglycemia. The medication profile was not updated with dose adjustment.

Upon patient record review, 1 of 14 (Patient #1) 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: Upon admission, patient medications include Glucotrol 10 mg, (dose 2 tabs), but 1 tab am, 1 tab lunch, 1 tab HS. The order is unclear. Furthermore, 3/23/23 SN visit documents that patient reported MD visit 3/20/23 and Glipizide was adjusted to 5 mg po in mornings. This order is unclear as to whether lunch and HS tabs are continued. The adjustment was made related to evening incidents of hypoglycemia. There is no indication of clarification of order.

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: 3/23/23 SN Visit, Patient reported Glipizide dosage adjustment during MD visit, secondary to evening episodes of hypoglycemia . The care plan was not updated to reflect this symptom or to address follow up assessment, education.

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 Visit #1: Aide emptied dirty bath water in sink after initial phase of bath and turned water faucet on and off with dirty gloves used to bathe patient.

Upon personnel record review, 1 of 13 (Personnel #6) 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.) ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(C) Shampoo, sink, tub, and bed 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 #6: The form utilized by the agency lists shampoo at sink, tub and bed, but tub was circled. Agency could not verify all 3 types of shampoo were demonstrated. Education provided.

Upon patient client record review, 2 of 14 (Patient #1, 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 #1 admitted with cardiac related diagnosis. Item #10010 of Comprehensive Assessment identifies diagnosis as "Cancer". Patient #9 admitted with Alzheimer's related diagnosis. Item #10010 of Comprehensive Assessment identifies Cancer as primary dx. There is no documented history or indication of cancer otherwise for either patient. Admin/DON states that software defaults that item to Cancer and nurse must have failed to change it. Patient #2: 4/12/23 IDG indicates by MSW that DNR is complete. However, no copy in EMR and administrator/MSW state the entry must have been an error because this patient does not have DNR.