Every finding on record at Envoy Hospice, LLC

Upon patient record review, 1 of 14 (Patient #2) 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 the Patient 02: The patient resides at a SNF, the medication profile includes orders for Miralax powder 17G by mouth one time a day for constipation, this is not included in the hospice plan of care. The hospice medication profile includes Lactulose 10gm/15ml give 30ml per day, this is not included in the medication profile at the SNF.

Upon patient record review, 2 of 14 (Patient #2, 4) 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 02: The patient resides at a SNF, the medication orders at the location includes orders for Miralax powder 17G by mouth one time a day for constipation, this is not included in the hospice plan of care. The hospice medication orders include Lactulose 10gm/15ml give 30ml per day, this is not included in the medication orders at the SNF. (Orders updated/corrected on site.) Patient 04: The patient record includes orders for wound care with dressing changes every 3 days, the order does not include designation of responsibility for who will provide the wound care. (Order clarified on site.)

Upon patient record review, 1 of 14 (Patient #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 10: Effective 4/24/24, the patient record indicates that the patient uses adult diapers due to night time incontinence, these are not included in the patient supply list.

Upon patient record review, 1 of 14 (Patient #10) 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 10: The patient record includes documentation that the patient was continent at the time of his admission on 8/14/23 and has since become incontinent at night as noted on 4/24/24, the plan of care does not include interventions and goals for the management of the incontinence.

Upon client record review, 5 of 14 (Patient #1, 3, 4, 5, 7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 01: The visit frequency orders for Spiritual Care are 1 time per month from 2/28/24 - 5/27/24. There were no spiritual care visits performed in the month of March. Patient 03: The Spiritual Care services are ordered for 2 times per month effective 2/26/24, the patient received 1 visit for the month of March, and 1 visit in the month of April. Patient 04: The plan of care includes wound care orders with interventions for weekly measurements of the sacral wound. A SN visit was performed on 4/18/24, 5/1/24, 5/10/24, 5/23/24 and 5/24/24 with no weekly measurement performed. Evidence in the patient records indicates that a foley catheter was placed on 5/1/24 at the caregivers request due to caregiver limitations. The RN documented placement of a foley catheter 16fr, 10cc, there is no evidence in the record that a verbal or written MD order was obtained at the time of placement. A written order was entered on 5/17/24. Patient 05: The plan of care effective 3/6/24 includes frequency orders for Spiritual Care, 1 time per month for 4 months and 1 prn, there are no Spiritual Care visits made for the month of March, April or May 2024. Patient 07: The plan of care includes frequency orders for MSW as 2 times per month from 4/17/24 - 6/15/24, the record includes 1 visit made on 5/3/24.

Upon patient record review, 1 of 14 (Patient #2) 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 02: The hospice aid task assignment does not include safety precautions including oxygen, falls, or bleeding.

Upon patient record review 3 of 14 (Patient #1, 3, 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 01: Hospice aide frequency orders are entered for 5 times per week effective 6/2/24, the patient received 3 visits from 6/2/24 - 6/8/24, one visit was declined by the primary caregiver on 6/6/24, no additional documentation was made. Patient 03: Hospice aide frequency orders are entered for 5 times per week effective 3/31/24, the patient received 4 visits the week of 4/21/24 - 4/25/24 and the week of 5/26/24 - 6/1/24. Patient 05: Hospice aide frequency orders are entered for 1 visit per week effective 3/6/24, evidence in the patient record indicates that aide services were not provided until 4/26/24.

Upon patient record review 1 of 14 (Patient #8) did not have evidence in the patient record that the hospice aides report: • Changes in the patient's medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities • Hospice aides must also complete appropriate records in compliance with the hospice's policies and procedures Patient 08: Hospice aide frequency orders are entered for 3 visits per week effective 4/29/24, the hospice aide documented in her time sheet, 1 refused/declined visit the week of 5/5/24 - 5/11/24, 2 refused/declined visits the week of 5/12/24 - 5/18/24, 2 refused/declined visits the week of 5/19/24 - 5/25/24, and 2 declined/refused visits the week of 5/26/24 - 6/1/24 the hospice aide failed to enter a clinical note or to notify the RN of the refused/declined visits for a potential need for change in the 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. The volunteer cost savings for 2023 is equivalent to 2.56 percent of the total patient care hours of all paid hospice employees and contract personnel.

Upon patient client record review, 2 of 14 (Patient #2, 3) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 02: The patient was admitted on 2/17/24 and resides in a long term care/skilled nursing facility, the Medicaid Hospice Benefit Election form indicated a start date of 2/16/24 and was signed on 2/16/24. Patient 03: The patient was admitted on 12/28/23 and resides in a long term care/skilled nursing facility, the Medicaid Hospice Benefit Election form was signed on 12/19/23 with an indicated start date on 12/19/23.