Every finding on record at Dunes Hospice LLC

Upon patient record review, 1 of 5 (Patient #2) 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: There is evidence in the record of a spiritual assessment completed on paper by the admission nurse which identified a spiritual problem for the patient; Fear and/or anxiety of dying with goals and interventions. The spiritual problem was not included on the Plan of Care on the computerized record and there is no evidence of follow up by the IDG regarding the spiritual problem. There is no evidence in the record that the spiritual problem: Fear and/or anxiety of dying was resolved. (Corrected on site.)

Upon patient record review, 1 of 5 (Patient #2) 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 #2: There is evidence in the medical record that the plan of care contained a PRN frequency order for the Social Worker. SW visit PRN frequency: SW to see patient 1X month in July 2024, then 2X month beginning August 2024. Which is not a detailed statement of the scope and frequency to meet the patient's individual needs. (Corrected on site.)

Upon patient record review, 2 of 5 (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 medications and treatments. Patient #1: The Plan of Care has a duplicate medication on 7/20/24 for MiraLAX 17 gm by mouth mixed with 8 oz. water or juice once daily as needed. Corrected on site.) Patient #3: The Plan of Care contains Baqsimi 3mg/actuation spray. Instill 3 mg in nostril PRN for low blood sugar. There is not indication of the blood sugar at which the drug should be given. (Corrected on site.)

Upon patient record review, 1 of 5 (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 equipment and supply needs. Patient #1: There is evidence in the medical record of a nurse's note of 8/6/24 "to address on going skin concerns, wheelchair pad requested from Dunes". There is no evidence of an order for wheelchair pad. (Corrected on site.)

Upon patient record review 1 of 5 (Patient #5) 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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #5: There is evidence in the medical record on 7/25/24 the HHA noted "patient has small open area in vaginal area orange cream applied." No creams are listed on the HHA plan of care.

Upon patient record review 12 of 23 (Patient #4,9,10,11,12,13,15,16,17,19,21,22) 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 9,16,17: The medical record does not contain an MSW or SC assessment with in 5 days. Pt refused MSW and SC and there is no evidence in the comprehensive assessment the RN completed the social services or spiritual assessment. Patient 4,10,12,13,15,19,21,22: The medical record does not contain evidence of a SC assessment completed with in 5 days and SC was refused. There is no evidence the nurse completed the assessment with in 5 days. Patient 11: The medical record does not contain evidence of a SC assessment completed with in 5 days.

Upon patient record review, 4 of 23 (Patient #1,2,6,23) 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: Patient 1: The medication profile contains orders for ES Tylenol, Colace. The facility did not have these medications on their MAR. The facility MAR contained Aplisol, Loperamide, Senna and these were not included in the hospice medication profile. Corrected on site. Patient 2: The Hospice medication profile 6/12/24 contains an order for Levothyroxine 112mcg, the facility MAR has Levothyroxine 137mcg updated on 4/4/24. Medication profile 6/12/24 has acetaminophen 325 and Senna orders. The facility MAR does not contain these medications. Corrected on site. Patient 6: The medication profile contains an order for Lorazepam 0.5ml Q2 hours prn, the facility MAR has give 0.25ml Q2 hours prn. The medication profile has fleets enema, the facility MAR does not contain this order. Corrected on site. Patient 23: The medication profile 6/19/23 contains Polyethylene Glycol with no diluent.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 4 of 23 (Patient #9,10,14,17) 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 9: The POC contains evidence of pt having a G tube. There is no care plan included on the POC for a G tube. Pt is receiving comfort feedings and there is no risk for aspiration care plan included on the POC. Corrected on site. Patient 10: Pt is taking Eliquis, has an open wound and there is no evidence of a risk for bleeding care plan. Corrected on site. Patient 14: The POC contains evidence pt is diabetic and receiving insulin. There is no endocrine care plan on the POC. Corrected on site. Patient 17: The POC contains evidence pt is diabetic, on Glipizide and there is no endocrine care plan on the POC. Corrected on site.

Upon patient record review, 20 of 23 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20) 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: Patients 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20: The most recent POC's contain orders for SN 2 times a week and 2 prn weekly for symptom control which is not a detailed statement of the scope and frequency to meet individual patient needs.

Upon patient record review, 8 of 23 (Patient #1,2,6,7,10,19,21,23) 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 POC contains orders for ES Tylenol, Colace. The facility did not have these medications on their MAR. The facility MAR contained Aplisol, Loperamide, Senna and these were not included in the hospice POC. Corrected on site. Patient 2: The Hospice POC 6/12/24 contains an order for Levothyroxine 112mcg, the facility MAR has Levothyroxine 137mcg updated on 4/4/24. POC 6/12/24 has acetaminophen 325 and senna orders. The facility MAR does not contain these medications. Corrected on site. Patient 6: The POC contains an order for Lorazepam 0.5ml Q2 hours prn, the facility MAR has give 0.25ml Q2 hours prn. The POC has fleets enema, the facility MAR does not contain this order. Corrected on site. Patient 7: The POC 6/19/24 contains an order "Cleansing with solution" does not indicate type of solution Patient 10: POC 6/19/24 contains part of an order "Cleanse with SN, pat dry". The order should have said NS. Patient 19: POC 2/21/24 contains order for "Insert/maintain 16F foley catheter, change foley catheter as needed for occlusion/dislodgement, Irrigate foley prn to maintain patency". There is no balloon size or directive of what or how much to irrigate with or how often it may be irrigated. Corrected on site. Patient 21: The POC 6/14/23 contains an order for SN 2 times per week starting 6/9/23. The EOB is for start of care 6/10/23. Patient 23: The POC 6/19/23 contains Polyethylene Glycol with no diluent.

Upon patient record review, 7 of 23 (Patient #1,2,4,13,14,15,17) 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 equipment and supply needs. Patient 1: Upon home visit finding the pt has a floor fall mat that was not ordered on the POC. Corrected on site. Patient 2: Upon home visit finding the pt has a floor fall mat, heel protectors, hoyer lift these items were not ordered on the POC. Corrected on site. Patient 4: Upon observation pt has heel protectors on. These were not included on the POC. Corrected on site. Patient 13: SN documented 5/13 "pt ambulated to bathroom with wheeled walker". There is no wheeled walker on the POC. Corrected on site. Patient 14: SN documented "Pt ambulated using a rollator assistive device to living room". There is not order for a rollator on the POC. Corrected on site. Patient 15: SN documented "pt is Hoyer lift at all times" on 5/6/24. There is no order on the POC for the Hoyer lift. Corrected on site. Patient 17: SN documented on 6/11/24 "pt uses wheelchair to ambulate". There is no order for a wheelchair. Corrected on site.

Upon client record review, 4 of 23 (patient #4,12,16,21) did not have evidence in the patient record that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 4: The POC contains orders for MSW 1 within 5 days and twice a month. The medical record contains evidence of visits by the MSW on 4/4,4/26,5/23, 6/13. There was not evidence of any refusals. Patient 12: On 6/10/24 the SN documented "writer wraps with Coban and kerlix to help with edema and on 5/28/24 "legs cleansed with wound wash, Aquaphor applied, wrapped with kerlix and Coban". There is no evidence of an order for this wound care. Corrected on site. Patient 16: The POC 5/8/24 contains order for "Cleanse with saline, pat dry, apply Z guard and cover with Optifoam. Change twice weekly with hospice RN visit and as needed if visible soiled". On 6/24/24 the SN documented "Optifoam dressing right hip clean, dry, intact". There is no evidence the dressing was changed during the hospice nurses visit as ordered or that the facility nurse had performed the dressing change. The SN documented 6/24/24 "Pt has a band aid on right knee, band aid removed, wound cleansed and dressing applied" There is no order for this dressing. Received order 6/26/24 for care of the knee. Patient 21: The POC 6/14/23 contains an order for SN 2 times per week starting 6/9/23 Pt was not admitted until 6/10/23. The nurse visited the pt one time that week on 6/10/23 There was no second visit made that week, it was a Saturday. The week of 6/11-6/17 the pt was visited by the nurse on 6/13,6/15,6/16 with no evidence of visit being PRN or an order for the extra visit.

Upon patient record review, 3 of 23 (Patient #21,22,23) did not have evidence the hospice offers bereavement counseling that includes: Patients 21,22,23: The Bereavement POC's for the agency are all them same regardless of the patient's bereavement risk level. They have Low, average, moderate and high risk and the POC's remain the same for the bereavement follow up. There is no evidence the bereavement services reflect the needs of the bereaved.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon patient record review, 7 of 23 (Patient #3,5,6,7,10,11,17) did not have evidence in the patient record that hospice aide assignments and duties are: Patient 3: The aide POC 6/6/24 contains documentation by the SN "pt and/or caregiver are cognitively able to make decisions in personal care". The patients Hospice Dx is End Stage Alzheimer's. Corrected on site. Patient 5: The aide POC 4/3/24 contains documentation by the SN "pt and/or caregiver are cognitively able to make decisions in personal care". The patients Hospice Dx is End Stage Alzheimer's. Corrected on site. Patient 6: The aide POC 4/17/24 has an order to change linens 3x a week and PRN and "pt and/or caregiver are cognitively able to make decisions in personal care". The patients Hospice Dx is End Stage Alzheimer's. Corrected on site. Patient 7: The aide POC 4/22/24 contains documentation by the SN "pt and/or caregiver are cognitively able to make decisions in personal care". The patients Hospice Dx is End Stage Alzheimer's. Corrected on site. Patient 10: The aide POC has orders for aide 3 times per week. The aide tasks are ordered to be completed 7 times a week. Corrected on site. Patient 11: The aide POC 4/29/24 contains documentation by the SN "pt and/or caregiver are cognitively able to make decisions in personal care". The patients Hospice Dx is End Stage Alzheimer's. Corrected on site. Patient 17: The aide POC 5/9/24 contains documentation by the SN "pt and/or caregiver are cognitively able to make decisions in personal care". The patients Hospice Dx is End Stage Alzheimer's. The aide POC contains an order for change linens weekly and PRN. Corrected on site.

Upon patient record review 8 of 23 (Patient #3,6,7,8,9,10,13,17) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 3: The Aide POC 6/6/24 contains orders for a shower twice a week. There is evidence the aide showered the pt on 6/17,6/19,6/21 and 6/10,6/12,6/14 with no evidence of communication with the RN for the extra showers those weeks. Patient 6: The aide documented the pt refused linen change on May 28,29,30 and May 7,8,10 the pt's diagnosis is Alzheimer's there is no evidence the aide spoke with the nurse or caregiver to verify if the linens needed changed. The aide POC contains an order for a bath 2 times per week. The aide documented that a bath was given May 28,29,30 and May 7,8,10. There is not evidence the aide called to obtain an order to give the bath the third time those weeks. Patient 7: The aide documented on 5/31/24 "pt requested we shave face". This was not included on the aide POC and pt has dementia. Patient 8: The aide POC has ordered task of change linens 3 times per week. There is no evidence the aide changed the linens on visits 5/13,5/28,5/29,5/31. The task was omitted from their documentation. Note at the bottom of their documentation states "notified nurse of visit". Patient 9: Aide POC 5/14/24 contains orders for visits 3 times per week. The week of May 12-18 aide visited the 15 & 16, the week of May 26-June 1 the aide visited 28,29,30,31. There was no evidence of an order for the extra visit and no evidence of an refusal for the missed visit. Bed bath was ordered 2 times per week. The aide gave a bath all four visits the week of May 26-June 1. The bottom of the documentation aide documented "notified nurse of visit". Patient 10:The aide documented 6/18/24 they shaved the pt. On 6/11, 6/14 the aide gave a back rub. These were not ordered on aide POC, pt is taking Eliquis. The bottom of the documentation aide documented "notified nurse of visit". Patient 13: The aide POC has ordered tasks for 3 times a week for oral care, hair care and change linens. Aide visited June 18,19,21 and did not completed these tasks. They were omitted from their documentation, no refusal. The bottom of the documentation aide documented "notified nurse of visit". Patient 17: The aide POC has orders for a bath twice weekly. The aide documented they gave a bath on June 10,12,14 in the same week. The aide's documentation contains the ability to provide back rub and shave pt, these were documented as refused on June 12,21,24 they're not ordered on the aide POC.

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 the agency's volunteer hours for 2023 0.83%.

Upon personnel record review, 1 of 13 (Personnel #2 ) did not have evidence the alternate administrator's personnel record verifies that: Personnel 2: The personnel file does not include a signed job description for this role. Corrected on site.

Upon patient client record review, 15 of 23 (Patient #1,2,4,5,7,9,10,12,13,15,16,18,19,20,21) 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: The SN documented on 6/12/24 "EOL". This is not an approved abbreviation. Patient 2: The SN documented 5/15/24 "Performed wound care to sacrum as ordered". Patient 4: The SN documented on 6/6/24 "ML for Dr per family request". This is not an approved abbreviation. Patient 5: The SN documented on 5/21/24 "EOL". This is not an approved abbreviation. Patient 7: The SN documented 5/10/24 "To sacrum-cleansing with solution pat dry" and "inner thighs/abdominal fold-site cleansed", "barrier cream to carry tissues"No evidence of what they cleansed with. Patient 9: On 5/22/24 SN documents the following unapproved abbreviations "Bkfst, dgtr, PU". Patient 10: SN documented performing wound care on 6/11/24 though did not document how pt tolerated the wound care. On 6/4 "Dressing change to mid back wound care performed", 5/31 "Dressing change per MD order". Patient 12: The comprehensive assessment 4/30/24 the SN documented under cardiopulmonary "Oxygen as ordered". Does not indicate how much oxygen the pt is using. Patient 13: The SN documented on 6/10/24 "EOL, OPTH, FN". On 6/3 "LBM,FN, BLL". These are not approved abbreviations. Patient 15: SN documented on 6/17/24 "wound care provided as ordered" and did not state how pt tolerated the wound care. The approved abbreviation for extended care facility is ECF, the nurse documented ecf on 6/17/24. On 5/21,5/28,6/3,6/10 the SN documented "Pt continues on daily nursing visits for wound care". There is no order for daily nursing visits and the nurses are not visiting daily. Patient 16: The SN documented 6/17/24 "wound care provided" and on 5/29/24 "Performed wound care to right hip". No evidence the SN followed POC. Patient 18: SN documented "FN". This is not an approved abbreviation. Patient 19: The MSW documented 2/26/24 "EOL and cg". These are not approved abbreviations. Patient 20: SN documented 4/29/24 and 4/26/24 "Wound care provided". There is not evidence the order was followed. Patient 21: SN documented on 6/11/23 "U/A found patient lying supine..." and "right s/c", 6/24/23 "Smit's FH called" which is approved for family history and not approved as documented.

Upon client record review, 8 of 23 (Patient #1,7,9,10,11,20,22,23) 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 1: The POC 6/12/24 contains an order for SN 2 times per week. The SN made visits June 3,5,6 and there is evidence they were routine visits and not PRN. Patient 7: Pt has wound care orders to be completed by Hospice nurse each visit and facility nurse when hospice is not present. The hospice nurse visited pt 5/17/24 there was no documentation wound care was performed or had already been completed by facility nurse. Patient 9: SN documented 6/5/14 "Peg tube insertion site is free from infection, dressing became dislodged and was replaced". There is no evidence of an order for the dressing on the POC. POC 5/15/24 "G tube to be flushed daily by facility staff". There is no order for what or how much to flush the G tube with. There are no orders for site care or dressing changes. Corrected on site. Patient 10: SN documented 4/26/24,5/31/24, 6/4/24 "cleanse with wound wash, pat dry, apply Santyl, cover with foam". The documentation is not past tense and the order was to wash with normal saline. Patient 11: The POC has MSW orders for 2 times per month. The MSW saw the pt one time in May on May 9. There is no evidence of a refusal of visit. Patient 20: The SN documented 4/26/24 "Pt transferred with use of Hoyer lift to hospice bed per writer and facility aide". There is no order for a Hoyer lift. Patient 22: The SN documented 5/24/23 "Zinc oxide paste applied and small sacral dressing placed". The order on POC 6/15/23, order date 6/6/23 is for coccyx and sacrum, cleanse with wound wash. Pat dry. Apply Zguard and cover with foam dressing. Change twice weekly by Hospice RN.

Based on record review and interview, the agency failed to follow agency policy for the disposal of controlled drugs in the patient's home in 2 of 4 clinical records reviewed. (#1, #2) The findings include: 1. Review of an agency policy on 6/14/2022, titled "Home Use and Disposal of Controlled Substances" dated October 2014, stated, "... After the patient dies or the drugs are discontinued, and therefore no longer needed, the qualified hospice personnel are responsible for the destruction, and should collect the drugs and dispose of them as determined by the procedures identified in the policy. Disposal of drugs will occur on site. Nurses must never transport drugs from the home. ... The hospice program must document in the clinical record the following information related to the disposed medications: The type of controlled substance, dosage, route of administration, and quantity, the time, date, and manner in which the disposal occurred. The drug disposal documentation should be maintained in the patient's medical record...." 2. Clinical record review on 6/14/2022, for patient #1, start of care 3/4/2021, evidenced an agency document titled "Pharmacy Uploads" which indicated the patient was provided 3 fentanyl (a narcotic pain medication) patches on 3/24/2021. Review of an agency document titled "Transfer/Discharge/Death Summary" electronically signed by registered nurse (RN) D and dated 3/30/2021, evidenced the patient requested a discharge from the agency due to dissatisfaction with the services. Review of agency documents titled "Medication Destruction Record" signed by RN D and dated 3/30/2021, indicated the method of disposal for all the patient medications except for fentanyl was disposal in coffee grounds. Review indicated 2 fentanyl patches were disposed of and the method of disposal for the fentanyl patch was not applicable and indicated the patches were cut up and destroyed in kitty litter. Review indicated the patient signed the form listing the patient's medications except for fentanyl. Review indicated the patient refused to sign the form listing the fentanyl. During an interview on 6/14/2022, at 10:00 AM, the family and patient care coordinator indicated all medications are the property of the patient and no medications are to be brought back to the office. During an interview on 6/14/2022, at 11:06 AM, RN D indicated narcotic medications are not to be removed from the patient's home. RN D indicated she has never brought back patient medications to the agency office. During an interview on 6/14/2022, at 1:15 PM, RN D indicated she disposed of the patient's medications in coffee grounds at the patient's home with the patient at time of discharge except for the fentanyl. When queried why the fentanyl was disposed of in kitty litter when the other medications were disposed of in coffee grounds, RN D indicated she took 2 fentanyl patches from the patient's home because the patient gave RN D the fentanyl patches after RN D had destroyed the other medications. RN D indicated the patient was upset regarding the lack of pain management, and RN D stated, "I was flustered." RN D indicated after she left the patient's home, the patient called her to inform her the nurse should not have taken the fentanyl patches from her home. RN D indicated she returned within 30 minutes to the patient's home with the fentanyl patches intact and indicated the patient refused to take the fentanyl patches back and refused to sign the medication disposal form. RN D indicated she marked "NA [not applicable]" on the disposal form because she did not destroy the fentanyl patches when she removed them from the patient's home. RN D indicated she brought the fentanyl patches to the agency's office and cut them up and placed them in kitty litter with another staff member as witness and then marked on the medication disposal form the patches were cut up and disposed of in kitty litter. 3. Clinical record review on 6/14/2022, for patient #2, start of care 1/13/2021, evidenced an agency document titled "Pharmacy Uploads" which indicated the patient was provided 30 pills of lorazepam (a narcotic medication to treat anxiety) on 9/3/2021, 3 fentanyl patches on 9/3/2021, and 20 milliliters (ml) of morphine (a narcotic pain medication) on 8/6/2021. Review of an agency document titled "Transfer/Discharge/Death Summary" electronically signed by registered RN E and dated 9/10/2021, evidenced the patient was discharged from hospice services due to increased functionality. Review indicated the RN destroyed the patient's medications. Review of a document titled "Controlled Drug Administration Record" indicated there was 7 ml of morphine remaining as of 8/17/2021, 14 pills of Lorazepam remaining as of 9/9/2021, and 2 fentanyl patches remaining on 9/8/2021. Review failed to evidence the date, time, and method of medication destruction per agency policy. During an interview on 6/14/2022, at 1:47 PM, the family and patient care coordinator indicated the lorazepam, morphine, and fentanyl were destroyed and indicated there was not record of the date, time, and method of medication destruction.