Every finding on record at Eminent Hospice Care, Inc.

Observed in Tracer Activities. There was no evidence that the after action report was reviewed by the committee as there were no documented after action reports for the last 2 years. The hospice surveyor reviewed and validated this with the Director of Professional Services. Observed in Tracer Activities. During the Emergency Management tracer activity the hospice surveyor found that the organization had not completed an After- Action report for the last 2 years to make updates or improvements in the Emergency Plan. This was reviewed and validated with the Director of Professional Services.

Observed in Patient Home. In 1 of 3 home visits conducted, the hospice surveyor noted on HOSRRHV #2 that the Metformin was held on 12/19/24 due to a low blood glucose there were no orders to show when the staff could restart the medication. It was currently on the medication list and patient was receiving the medication daily. This was reviewed and validated with the Director of Professional Services. Observed in Record Review. In 7 of 12 patient records reviewed, the Hospice surveyor noted the HOSRRHV #2, HOSRRHV #3, HOSRRNHV #1, and HOSRRNHV #4 the patient had both Bisacodyl 10 mg rectal suppository and Milk of Magnesia 1200 mg/5 ml prn for constipation and it is not clear when one is taken over the other. Additionally, the surveyor observed HOSRRHV #3 and HOSRRNHV #2 the patient had an order for acetaminophen 1000mg po twice a day as needed for pain and Advil 200 mg orally twice a day as need for pain. It is not clear when to take one over the other. In HOSRRNHV #1 the patient had an order for Tylenol 325 mg 2 tablets po and Tylenol 650 mg suppository every 6 hours and as needed for mild pain and fever >100. It is not clear when to take one versus the other. In HOSRRNHV #3 the patient had an order for senna 50mg-8.6mg tab 2 tab daily and Dulcolax 10 mg suppository daily as needed for constipation. No indication when to take one over the other. In HOSRRNHV #7 the patient has orders for Ibuprofen 600mg tab 1 every 6 hours as needed for pain, Norco 5mg-325 mg tab one twice a day as needed for pain, and Acetaminophen 650 mg rectal suppository every 6 hours as needed for pain or fever >100. There is no indication when to take one over the others. This was reviewed and validated with the Director of Professional Services. Observed in Record Review. In 2 of 12 patient records reviewed, the hospice surveyor noted that HOSRRNHV #7 and in HOSRRDC #2 had an order on the plan of care for 2 Liters of Oxygen as needed for an SPO2 <90%. there was another order to titrate the Oxygen 2 to 5 Liters via face mask if SPO2 <90%. In the nursing comprehensive assessment the RN documented that the patient was on 2-5 liters of Oxygen as needed. The POC included conflicting oxygen orders. This was reviewed and validated with the Director of Professional Services.

Observed in Record Review. In 7 of 12 patient records reviewed, where aide services were required the HOS surveyor noted that the aide care plan did not include specific precautions. In HOSRRHV #1 the patient is on an anticoagulant and is a fall risk and neither were included in the aide POC. In HOSRRHV #2 the patient is a fall risk and this is not included in the aide POC. In HOSRRNHV#1 and in HOSRRNHV #6 the patients had wounds and there is no documentation in the aide POC for this precaution. In HOSRRNHV #2 the patient is a fall risk and on continuous Oxygen and neither were included in the aide POC. In HOSRRNHV #7 and in HOSRRDC #2 the HHA assignment had a range order for oxygen documented as 2-5 Liters as needed. This was reviewed and validated with the Director of Professional Services.

Observed in Patient Home. In 1 of 1 home visits conducted, where the home health aide provided personal care the Hospice surveyor noted in HOSRRHV #1 that the aide failed to brush the patient's teeth and clean her dentures, apply deodorant, and lotion as instructed on the POC for each visit. This was reviewed and validated with the Director of Professional Services.

Observed in Record Review. In 3 of 12 patient records reviewed, where home health aide services were ordered they were not supervised every 14 days per policy of law and regulation. In HOSRRHV #1 there was an instance where there were 42 days between supervision and in another instance there were 15 days. In HOSRRHV #2 there were 28 days between supervisory visits and another in another instance there were 15 days. In HOSRRHV #3 there was one instance where a supervisory visit was done on day 15. In HOSRRNHV #1 there were thee instances from start of care to present where the aide was supervised on day 15. This was reviewed and validated with the Director of Professional Services.

Observed in Tracer Activities. In 4 of 9 HR files reviewed, the competencies were not defined for the Hospice Medical Director, Director of Professional Services, Volunteer Coordinator, and the Bereavement Coordinator.. This was reviewed and validated with the Director of Professional Services.

Observed in Patient Home. In 2 of 3 home visits conducted, on HOSRRHV #1 where the CHHA performed a shower the HOS surveyor noted that the CHHA used the same pair of gloves for washing the clean and dirty areas e.g. perineal care. The aide then dressed the patient using the same gloves. The HOS surveyor also noted that prior to taking the patient in for her shower the aide applied hand sanitizer multiple times to her gloves. The aide failed to follow the Hand Hygiene policy 9-009.1. Additionally, in HOSRRHV #1 and HOSRRHV #2 the HHA used an Omron cuff and the RN utilized a Fenghou electronic blood pressure cuff. Both the RN and the HHA cleansed their cuffs with an alcohol wipe which is not an approved cleaner per the manufacturer's guidelines. The surveyor noted that the electronic cuffs were not on the Cleaning and Disinfecting Vital Sign Equipment Policy. These issues were reviewed and validated with the Director of Professional Services.

Observed in Record Review. In 1 of 12 patient records reviewed, it was noted that there was no evidence of a Registered Nurse comprehensive assessment for the interdisciplinary team completed every 15 days. For example, a review of the medical record for HV#1 revealed no documented evidence of a Registered Nurse comprehensive assessment completed during week 8 of the first benefit period. This observation was reviewed with the Administrator.

Observed in Competency Session. A review of 2 of 2 Hospice Aide Human Resource files revealed that the organization did not ensure that an annual competency evaluation was completed. For example, there was no documented evidence that an annual on-site visit to the location where a patient was receiving care in order to observe and assess each aide while the aide was providing care was performed for Hospice Aide #1 and Hospice Aide #2. This observation was reviewed with the Administrator.