Every finding on record at Envoy Hospice, LLC

Upon patient record review 5 of 19 (Patient #2, 3, 5, 10, 11) 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 2: Patient admitted 6/1/23. Initial psychosocial assessment completed 6/8/23. Patient 3: Patient admitted 7/11/23. Initial psychosocial assessment completed 8/3/23. Patient 5: Patient admitted 11/29/23. Initial psychosocial assessment completed 12/6/23. Patient 10: Patient admitted 1/30/24. Initial psychosocial assessment completed 2/6/24. Patient 11: Patient admitted 4/29/23. Initial psychosocial assessment completed 5/5/23.

Upon patient record review 3 of 19 (Patient #6, 9, 10) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 6, 9, 10: No initial spiritual assessment documented in patient's medical record.

Upon patient record review, 2 of 19 (Patient #1, 4) 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 1: Patient has topical medications listed on medication profile: asperflex and nystatin. No administration site ordered. Patient has lomotil listed on medication profile. No dose or frequency listed for this medication. Patient 4: Patient has clonidine patch listed on medication profile. Frequency is listed as both daily and weekly. Ativan, zofran, and morphine injectables listed on medication profile. No evidence of route for these medications.

Upon patient record review, 7 of 19 (Patient #1, 3, 6, 7, 11, 12, 13) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patients 1, 3, 6, 7, 11, 12, 13 did not have evidence of bereavement risk assessment in medical record.

Upon patient record review, 2 of 19 (Patient #8, 13) 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 8 and 13: Patient is taking eliquis and no bleeding precautions documented in patient's plan of care.

Upon patient record review, 2 of 19 (Patient #1, 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 1: Patient has topical medications listed on medication order: asperflex and nystatin. No administration site ordered. Patient has lomotil listed on medication order. No dose or frequency ordered for this medication. Patient 4: Patient has clonidine patch listed on medication order. Frequency is listed as both daily and weekly. Ativan, zofran, and morphine injectables listed on medication order. No evidence of route for these medications.

Upon patient record review, 4 of 19 (Patient #1, 2, 3, 12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: RN visits on 5/16/24 and 5/21/24 documented the RN drained 500ml fluid from aspira drain. There is no physician's order for aspira drain care. Patient 2: SW is ordered as once a month. No evidence of visit made in May 2024. Patient 3: SN ordered twice weekly. RN completed routine visits on 5/20, 5/22, 5/24. Patient 12: SC ordered twice monthly. Only one visit documented 4/29/24. SC visit opened on 4/25 with no visit made or assessment completed this date.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon patient record review, 13 of 19 (Patient #1-13) 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 1-5, 7, 10-12: Vital signs on aide care plan without parameters. Patient 2: Identified as high fall risk with no fall precautions on aide care plan. Patient 3: Identified as high fall risk and aspiration risk. No fall precautions or aspirations precautions on aide care plan. Patient 4: Aide care plan included tasks complete bed bath, partial bed bath, shower, shampoo listed as "per frequency" instead of frequency provided. Patient 5: Aide task turn and reposition is listed as per frequency. Patient 6: Identified as high fall risk and aspiration risk. No fall precautions or aspirations precautions on aide care plan. Patient also on oxygen and has no oxygen precautions on aide care plan. Patient 8: Aide tasks bed bath, linen, shampoo, shave, turn and reposition- no frequencies. Patient taking eliquis without bleeding precautions on aide care plan. Patient 9: Aide tasks bed bath, linen, shampoo, shave turn and reposition without frequencies. Identified as high fall risk and aspiration risk. No fall precautions or aspirations precautions on aide care plan. Patient also on oxygen and has no oxygen precautions on aide care plan. Patient 10: Aide task ROM frequency is "if requested" Patient 13: Aide task turn and reposition without frequency. Patient taking eliquis without bleeding precautions on aide care plan.

Upon patient record review 11 of 19 (Patient #1, 2, 3, 4, 5, 6, 7, 9, 11, 12, 13) 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 1: ROM ordered every visit. Not performed on 5/13 and 5/15. VS ordered every visit. Not performed on 5/13, 5/14, 5/16, 5/17. Max assist with transfers ordered every visit. Not documented 5/16, 5/17, 5/20, 5/23, 5/24, 5/25, 5/31. Provide pivot assist with transfers ordered every visit. Not performed 5/16, 5/17, 5/25, 5/30, 5/31, 6/1 Patient 2: Shave is ordered every visit. Not performed 5/18, 5/23. Vital signs ordered every visit. Not performed on 5/18, 5/21, 5/23, 5/25, 5/28, 6/1. ROM ordered every visit. Not performed 5/21, 5/25, 5,28, 6/1, 6/4. Patient 3: VS ordered every visit. Not performed during any aide visit 5/13-6/3. Change linen ordered every visit. Not performed 5/13, 5/22, 5/31. Patient 4: ROM ordered every visit. Not performed 5/18, 5/25, 5/28, 5/30, 6/4 VS ordered every visit. Not performed 5/18, 5/21, 5/25, 5/28, 5/30, 6/4. Patient 5: ROM ordered every visit. Not performed 5/13, 5/15, 5/17, 5/29, 5/31, 6/3. Vital signs ordered every visit. Not performed 5/13, 5/15, 5/22, 5/29, 5/31, 6/3. Patient 6: Change linen ordered every visit. Not performed 5/31. Patient 7: ROM and vital signs ordered every visit. Not performed 5/22, 5/24, 5/29, 5/31. Patient 9: Mouth care ordered every visit. Not performed 5/13. Patient 11: ROM and VS ordered every visit. Not performed 5/21, 5/25, 5/28, 5/30, 6/1. Patient 12: Change linen ordered every visit. Not performed 5/6, 5/10, 5/13, 5/15, 5/17, 5/29. Patient 13: ROM and VS ordered every visit. Not performed 5/18, 5/25, 5/28, 5/30.

Upon patient record review 5 of 19 (Patient #1, 2, 4, 9, 11) 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 1: Patient admitted 5/12/24. First aide visit 5/13/24. No evidence of aide supervisory visit performed. Patient 2: No evidence of aide supervisory visit from 4/24 to 5/15. Patient 4: No evidence of aide supervisory visit after 5/10/24. Patient 9: Aide supervisory visits documented 5/20/24 and 6/4/24. Patient 11: No evidence of aide supervisory visit between 4/23 and 5/15.

Upon patient record review, 1 of 19 (Patient #4) did not evidence that each patient record contains physician orders. Patient 4: There was no evidence of physicians order for level of care change: GIP, continuous care.

Upon patient record review, 1 of 19 (Patient #2) 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 2: Consents incomplete: advance directive section with several boxes not marked yes or no. Payor source section was not completed.

Upon patient record review, 1 of 19 (Patient #8) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 8: Wound care order for left buttocks. Order does not include frequency or who is performing wound care.

Upon patient record review, 4 of 19 (Patient #4, 6, 7, 8) did not have evidence that the hospice provided the following information to the SNF: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice's 24-hour on-call system • Hospice medication information specific to each patient • Hospice physician and attending physician (if any) orders specific to each patient