Every finding on record at East End Hospice, Inc.

Observed in Individual Tracer. In 13 of 14 patient records reviewed, The surveyor noted that (RRHV#1) that a spiritual assessment was not completed that considered the spiritual concerns or needs identified by the patient or family, such as despair, suffering, guilt, and forgiveness. The only documentation was the identification of the patient's religion and that pastoral care was deferred. There was no evidence that the chaplain had attempted to contact/visit the patient or that the patient/cg refused the assessment. In (RRHV#2, RRHV#3, and RRNHV#5-14), the spiritual assessment was limited to confirming/discussing religion and was completed by either the nurse or social worker and there was no evidence that the chaplain attempted to contact the patients or that the patient's refused a visit from the chaplain. In discussion with the president, it was confirmed that it was not the organizations practice to include a pastoral assessment by the chaplain, and the chaplain only visits when it is requested. Observed in Record Review. In 3 of 14 patient records reviewed, The surveyor noted that (RRNHV#5) several components of the psycho-social assessment in the EMR were not completed and were blank, for example, there was no assessment of the patient's coping mechanisms (RRNHV#10), the areas related to family dynamics, end of life issues, advanced directives and funeral planning and most of the home safety assessment were not completed. In (RRNHV#13), the psycho-social assessment was incomplete and did not assess the discourse in the family related to the patient living arrangements, family dynamics, and the patient's children, as noted in a visit note. There was no assessment for this 50 year old patient need at end of life issue including, advanced directives, funeral planning, history of addiction (use of lock box in home). Also, there was no assessment of lifestyle assessment including employment, legal, and financial needs. This was confirmed with the president.

Observed in Record Review. In 4 of 14 patient records reviewed, The surveyor noted (RRHV#1) that the patient had an indwelling Foley catheter, developed a UTI and had a wound; however a temperature was not assessed. In (RRNHV#5), there was no assessment of the severity of the patient's agitation. In (RRNHV#8) there was no assessment of the severity of diarrhea related to C-Diff, also in (RRNHV#13) there was no assessment of the patient's G-tube feeding tolerance and risk for aspiration, and there was no assess of patient's goal for pain management, as required by the pain assessment policy. This was confirmed with the president.

Observed in Individual Tracer. In 10 of 14 patient records reviewed, The surveyor noted (RRHV#3) that the plan of care did not include any measurable outcomes. For example the goal for pain was effective ongoing management of chronic pain, verbalized understanding of Ekit medications, adheres to medication plan within two weeks. Others included effective bowel pattern maintained, progressive healing of wound within two weeks ,address issues of sadness and anxiety will be minimized/controlled. In (RRHV#4), the surveyor noted that the SN and MSW goals did not include measurable outcomes for goals including role stress (patient receives safe/appropriate care within two weeks, caregivers needs are not compromised throughout care. The assessment indicated the CG need for emotional support, Health care advocacy and understanding of disease process and anticipatory grief, however, there were no interventions to address the needs. In 13 of 14 records the MSW visit freq. was Q other week and did not include individual outcome expectations. ; also, most of the nursing goals did no include outcome measures or time frames for achieving them. For example in (RRNHV#4) the goal was stated effective ongoing management of chronic pain, effective bowel pattern maintained, demonstrate proper aspiration precautions and swallowing methods. In (RRNHV#5-12) there were no measurable outcomes for effective ongoing pain management, reduce evidence of agitation in 72 hours, optimal mobility within disease restrictions and address issues of sadness. In (RRNHV#7) the goal included resumption of baseline bowel pattern in 2 weeks, andoptimal mobility. In (RRNHV#12), there were no goals for sadness, anxiety or agitation. This was confirmed with the president.

Observed in Individual Tracer. In 2 of 4 home visits conducted, The surveyor noted that (RRHV#1) that the nurse used a spray bottle of Sanizide to disinfect equipment after use; however, did not follow the manufacturer's guideline to spray surface and maintain visibly wet for three minutes. Also, the product was only to be used on non-porous surfaces and it was used to clean both the plastic stethoscope and the fabric blood pressure cuff. The equipment was non sprayed to be visible wet. Also, in (RRHV#2), the nurse sprayed the product lightly onto a paper towel then used the paper towel to wipe down the equipment and thus was not visibly wet. This was confirmed with the president. Observed in Individual Tracer. In 1 of 4 home visits conducted, The surveyor noted (RRHV#3) that the aide did not carry hand hygiene supplies with her into the home, and depended on the patient to provide her with soap and paper towels. The bag policy indicated that staff should carry soap, paper towels and hand sanitizer. This was confirmed with the president.

Observed in Document Review. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by a condition level finding at 418.54 as significant issues with completing assessment and care planning, as per policy. This was confirmed with the president.

Observed in Record Review. The surveyor noted (RRNHV#5) that the patient was residing in a skilled facility; however, the plan of care did not identify the care and services that were needed and identify which provider was responsible for performing the functions that had been agreed upon and included in the plan of care. including medications, insertion, change and irrigation of the Foley catheter. This was confirmed with the president

Observed in Building Tour. The main electrical room barrier wall has spray foam around conduit that needs to be removed and resealed with an approved fire rated material. The Observation was witnessed by the Facility Manager. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.

Observed in Building Tour. The oxygen source valve was not labeled in the manifold tank room. The Observation was witnessed by the Facility Manager. Observed in Document Review. The annual inspection of Audible and Visual notification devices did not include an inventory. The Observation was witnessed by the Facility Manager.

Observed in Tracer Activities. The surveyor noted that there were two unopened boxes of cereal stored in the kitchen, that had both expired in 2025. This was confirmed with the hospice inpatient unit manager.

Observed in Individual Tracer. In 6 of 13 patient records reviewed, Confirmed by the Quality Manager. Documentation had not reflected an individual plan of care based on patient assessment and had not reflected measurable goals. Example: During review of HOSv#1, HOSv#2 HOSrr1 A goal had documented that pain would be controlled with the appropriate analgesic. Another goal had documented that agitation would be minimized or controlled .

Observed in Individual Tracer. In 1 of 3 Hospice visits observed and confirmed by the Quality Manager. The organization had not implemented its infection prevention and control activities when cleaning or disinfection of medical equipment. Example: During observation of HOSv#3 , The nurse had Utilized cavicide spray to disinfect equipment, however had not followed manufacturers guidelines to rewet equipment and allow to sit wet for 2 minutes per manufacturers guidelines.

Observed in Individual Tracer. In 2 of 13 patient records reviewed, Confirmed by the quality manager. The patient record had not contained an accurate medication list. Example: During review of HOSv#1 medications there had been several vitamins noted that patient had been taking on a regular basis as well as Tylenol PO and had not been documented on medication profile. During observation of HOSv#2 and review of patient record. The patient had taken Tylenol PO but the medication profile had only listed Tylenol suppository.

Observed in Record Review. In 1 of 1 patient records reviewed, the plan of care was not based on the patient's goals and the time frames, settings and services required to meet those goals. In HV #1, the surveyor noted the plan of care included the following non-measurable goals: anxiety is minimized or controlled. preservation of optimal pulmonary function. dementia goals indicated: family can safely provide care, max functional level within disease limits, provide safe home environment within 1 week. Social worker goal: address issues of sadness with no time frame. This was confirmed with the performance improvement manager.

Observed in Record Review. In 1 of 1 patient records reviewed, the plan of care did not include a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. In HV #1, the surveyor noted the aide visit frequency was 1 - 2 hours 3 -5 x's per week; however, the patient saw the patient five times per week and some visits were four hours long and others were three hours long. This was confirmed with the performance improvement manager.

Observed in Record Review. In 1 of 1 patient records reviewed, the plan of care did not include all drugs and treatment necessary to meet the needs of the patient. In HV #1, the surveyor noted the plan of care under nutrition indicated diet as tolerated. In addition, the plan of care included the following standing order that were not appropriate for the patient: for oxygen 2 liters via nasal cannula for shortness of breath; however, did not specify if prn, intermittent or continuous. Cortisone 1% cream twice daily prn topically for pruritus/skin irritation. For skin irritation: over the counter antifungal and/or antibiotic ointment or choice prn. For urinary incontinence or retention: insert 16Fr foley catheter. This was confirmed with the performance improvement manager.

Observed in Record Review. In 1 of 1 patient records reviewed, the organization did not provide the patient with care, treatment or services according to his or her individualized plan of care. In HV #1, the surveyor noted the plan of care indicated a nursing visit frequency of one time per week with 5 prn visits for pain and anxiety; however, the nurse made two visits the second week of service and neither visit met the prn visit criteria for pain or anxiety. Both visits appeared to be routine visits. This was confirmed with the performance improvement manager.

Observed in Patient Home. In 1 of 1 home visits conducted, the organization did not clean equipment according to manufacturer guidelines. For example, during HV#1 it was noted that the clinician used Caviwipes to clean their equipment but did not allow for the manufacturers recommended 'wet' time of 2 minutes prior to returning equipment to their bag. This was confirmed with the performance improvement manager.

Observed in Record Review. In 1 of 1 patient records reviewed, the hospice aide did not provide services that were included in the plan of care. In HV #1, the surveyor noted the aide stated in the home visit that they had been applying hydrogen peroxide, applying A&D and covering with a bandaid; however, this was not on the aide plan of care. This was confirmed with the performance improvement manager.

Observed in Patient Home. In 1 of 1 home visits conducted, the patient record did not contain all clinical information. In HV #1, the surveyor noted the medication profile included aspirin and levothyroxine; however, the patient's son reported the patient stopped taking both of the medications one month ago. Second example, the medication profile included omeprazole daily prn; however the actual frequency was once daily. Third example, the following prn medication did not include an indication on the medication profile: aleve and ibuprofen. Fourth example, the medication profile included the following medications that were discontinued per the patient's son one month ago: aspirin and levothyroxine. In addition, during the review of the clinical record, the documentation of the wound care provided last week indicated wound care per care plan; however, the documentation did not specify the care provided. This was confirmed with the performance improvement manager.

Observed in Patient Home. In 1 of 1 home visits conducted, the organization did not create an individualized emergency plan for the patient. In HV #1, the surveyor noted the individualized emergency plan in the patient' home folder was blank. This was confirmed with the performance improvement manager.