Every finding on record at Eden Hospice Inc.

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice's employees and Federal, state, tribal, regional, and local emergency management agencies.

Upon patient record review, 11 of 14 (Patients # 1, 2, 3, 4, 5, 6, 9, 10, 12, 13, 14) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient # 1, 2, 3, 4, 5, 6, 9, 10, 12, 13, 14) There was not evidence that the comprehensive assessment takes into consideration the imminence of death.

Upon patient record review, 1 of 14 (Patient #3) 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 # 3) Upon home visit, the hospice medication profile/plan of care contained a) Senna 8.6 mg 1 tab, oral, daily. b) Morphine Sulfate 20 mg/1ml solution, 0.25 ml, sublingual, every two hours as needed for pain. b) Ondansetron 4 mg, oral, take 1 tab by mouth every four hours as need for nausea and vomiting. c) Acetaminophen 650 mg suppository every four hours as needed for mild pain or fever greater than 100.4 degrees. d) Bisacodyl 10 mg, suppository, once a day as needed for constipation. Daughter stated they did not have the medication in the home. The nurse looked for the medications and they were not at this location.

Upon patient record review, 6 of 14 (Patients # 1, 2, 5, 9, 11, 14) 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) Patient's plan of care dated 7/17/25, the MSW was ordered PRN without a frequency for the PRN visits. Patient # 2) Patient's plan of care dated 4/18/25, the MSW and SC were ordered PRN without a frequency for the PRN visits. Patient # 5) Patient's plan of care dated 7/17/25, the MSW was ordered PRN without a frequency for the PRN visits. Patient # 9) Patient's plan of care dated 7/17/25, the MSW and SC were ordered PRN without a frequency for the PRN visits. Patient # 11) Patient's plan of care dated 6/19/25, the MSW was ordered PRN without a frequency for the PRN visits. Patient # 14) Patient's plan of care dated 9/26/24, the MSW and SC were ordered PRN without a frequency for the PRN visits.

Upon personnel record review, 1 of 14 (Personnel # 9) 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.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination 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 #9) There was no evidence of a competency to include communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff.

Upon patient record review, 8 of 14 (Patients # 1, 2, 4, 6, 10, 11, 13, 14) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient # 1) The aide plan of care dated 6/29/25 did not contain frequencies for the tasks of empty urine collection bag, record bowel movement, feeding assistance, and change linens. Patient # 2) The aide plan of care dated 4/18/25 did not contain frequencies for the tasks of record bowel movement and change linens. Patient # 4) The aide plan of care dated 7/13/25 did not contain frequencies for the tasks of turn and reposition, record bowel movement, feeding assistance, and change linens. Patient # 6) The aide plan of care dated 6/1/25 did not contain frequencies for the tasks of record bowel movements and change linens. Patient # 10) The aide plan of care dated 2/2/25 did not contain frequencies for the tasks of turn and reposition, empty urine collection bag, record bowel movements, and change linens. Patient # 11) The aide plan of care dated 5/29/25 did not contain frequencies for the tasks of turn and reposition, record bowel movement, encourage fluids if tolerated and not contradicted, and change linens. Patient # 13) The aide plan of care dated 9/9/24 did not contain frequencies for the tasks of turn and reposition, and change linens. Patient # 14) The aide plan of care dated 6/29/25 did not contain frequencies for the tasks of change linens.

Upon patient record review 1 of 14 (Patient # 14) 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 # 14) There was not evidence of an RN supervisory visit for the hospice aide between the dates of 9/9/24 - 9/26/24.

Upon personnel record review, 1 of 14 (Personnel # 9) did not have evidence in the hospice aide personnel file that a registered nurse made an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care. Personnel # 9) There was no evidence a registered nurse made an annual on-site visit to the patient's home.

Upon personnel record review, 9 of 14 (Personnel # 1, 2, 3, 4, 9, 10, 12, 13, 14) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel #1, 2, 3, 4, 9, 10, 12, 13, 14) There was not evidence the orientation process included hospice philosophy.

Upon personnel record review, 3 of 14 (Personnel # 4, 12, 13) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Patient #4, #12,#13) There was not evidence of an initial competency being performed and documented.