Every finding on record at Envoy Hospice, LLC

Upon patient record review, 5 of 19 (Patient #4, 5, 9, 10, 13) 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 04: The medication profile includes Aspercreme Lidocaine External Patch 4%, one patch daily, apply to affected area. The application site is not indicated. (Profile corrected on site.) Patient 05: The medication profile includes Nystop External powder 100,000U/GM apply to affected area as need for skin irritation/redness, it does not include an application site. (Profile corrected on site.) Patient 09: The medication profile includes Miralax 17GM packet, give 1 PO as needed for constipation, it does not include a diluent. (Profile corrected on site.) Patient 10: The medication profile includes Miralax 17GM packet daily, PO PRN constipation, it does not include a diluent. (Profile corrected on site.) Patient 13: The medication profile includes Miralax 17GM packet, give 1 PO as needed for constipation, it does not include a diluent. (Profile corrected on site.)

Upon patient record review, 1 of 19 (Patient #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 13: The patient was admitted on 4/10/24 with a primary diagnosis of liver cirrhosis, the plan of care does not include a problem statement with interventions and goals for the management of the disease.

Upon patient record review, 5 of 19 (Patient # 4, 5, 9, 10, 13) 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 04: Medication orders on 3/7/24 for Aspercreme Lidocaine External Patch 4%, one patch daily, apply to affected area. The application site is not indicated. (Order corrected on site.) Patient 05: The medication orders on 2/3/24 includes Nystop External powder 100,000U/GM apply to affected area as need for skin irritation/redness, it does not include an application site. (Order corrected on site.) Patient 09: The medication orders on 2/16/23 for Miralax 17GM packet, give 1 PO as needed for constipation, do not include a diluent. (Order corrected on site.) Patient 10: The medication orders on 5/20/24 for Miralax 17GM packet daily, PO PRN constipation, do not include a diluent. (Order corrected on site.) Patient 13: The medication orders on 4/10/24 for Miralax 17GM packet, give 1 PO as needed for constipation, do not include a diluent. (Order corrected on site.)

Upon client record review, 2 of 19 (Patient #5, 6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 05: The skilled nursing visits are ordered for 1 time per week, the patient did not receive a visit the week of 5/19/24 - 5/25/24. Patient 06: Orders for psychosocial visits are entered for 1 time per month from 3/29/24 - 5/27/24, there are no visits made during this time frame.

Upon patient record review, 1 of 19 (Patient #18) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 18: The patient died on 4/4/24, the bereavement plan of care includes post death follow up phone call with bereavement risk assessment within 2 weeks after the patients death, a post death condolence phone call within 1-5 days (was attempted), and a condolence card to be mailed within 2 weeks, there is no evidence in the patient record of these interventions being performed. (A bereavement assessment is documented on 6/17/24 with minimal input and no evidence of a phone call with the bereaved.)

Upon patient record review, 1 of 19 (Patient #1) 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 01: The patient was admitted on 5/9/24 with a foley catheter in place, then removed on 5/16/24, the hospice aide task assignment has not been updated to remove the foley catheter care from the aide task assignment. (Aide task assignment corrected on site.)

Upon patient record review 1 of 19 (Patient #6) 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 06: The visit frequency for the hospice aide is entered as 2 times per week. The patient received 1 visit the week of 5/12/24 - 5/18/24.

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 annual reported volunteer cost savings for 2023 is equivalent to 2.93%.

Upon patient client record review, 3 of 19 (Patient #1, 4, 7) 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 01: The patient was admitted on 5/9/24, the initial skilled nursing assessment for the patient was not signed and authenticated until 5/13/24. The visit on 5/10/24 performed by the MSW was not signed and authenticated until 5/13/24. Patient 04: A skilled nursing visit was performed on 3/6/24, the documentation was not completed, signed and authenticated until 3/18/24. A skilled nursing visit was performed on 3/4/24, the documentation was not completed, signed and authenticated until 3/7/24. A skilled nursing visit was performed on 3/8/24, the documentation was not completed, signed and authenticated until 3/24/24. A skilled nursing visit was performed on 5/22/24, the documentation was not completed, signed and authenticated until 5/30/24. A skilled nursing visit was performed on 5/24/24, the documentation was not completed, signed and authenticated until 6/2/24. A skilled nursing visit was performed on 5/28/24, the documentation was not completed, signed and authenticated until 6/2/24. A skilled nursing visit was performed on 5/31/24, the documentation was not completed, signed and authenticated until 6/2/24. A skilled nursing visit was performed on 6/5/24, the documentation was not completed, signed and authenticated until 6/12/24. A skilled nursing visit was performed on 6/7/24, the documentation was not completed, signed and authenticated until 6/12/24. A skilled nursing visit was performed on 6/10/24, the documentation was not completed, signed and authenticated until 6/16/24. A skilled nursing visit was performed on 6/12/24, the documentation was not completed, signed and authenticated until 6/17/24. A skilled nursing visit was performed on 6/14/24, the documentation was not completed, signed and authenticated until 6/18/24. Patient 07: The patient was admitted on 4/4/24, the documentation of the skilled nursing initial comprehensive assessment was not completed, signed and authenticated until 4/9/24.