Every finding on record at Envoy Hospice, LLC

Upon patient record review, 3 of 19 (Patient #5,6,9) 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 5: The RN documentation indicated that the patient was using oxygen at 4LNC and 2.5LNC. The active medication list has an order for oxygen 2LNC PRN for shortness of breath. No evidence that the active medication list includes 4LNC or 2.5LNC and no evidence that the current order includes a titration order to increase when needed. COS-Active medication list updated during survey Patient 6: The active medication profile has an entry for acetaminophen rectal supp 650 mg PRN every 6 hours for constipation. COS - active medication profile list to remove constipation as the PRN reason for use. Patient 9: Active medication list has MiraLAX, Colace, and Dulcolax all listed as PRN for constipation. No evidence that the active medication list included instructions on which medication to give first in the event of constipation. COS - new order written to update the active medication list during survey.

Upon patient record review, 1 of 19 (Patient #13) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days assessments. Patient 13: No evidence that a comprehensive assessment was completed by the RN every 15 days between 01/31/2025 and 02/20/2025. 20 days between assessments.

Upon patient record review, 5 of 19 (Patient #1,3,5,7,12) 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 1: The clinical documentation indicated that the patient was a risk for falls. No evidence of problems, goals, and interventions related to risk for falls included in the current plan of care. COS - New order written to update the plan of during survey. Patient 3: The medical record indicated that the patient currently takes Xarelto for blood thinner. No evidence of problems, goals, and interventions related to risk for bleeding included in the current plan of care. COS - New order written to update the plan of during survey. Patient 5: The medical record also indicated that the patient has a related diagnosis of depression. No evidence of problems, interventions, and goals related to depression included in the current plan of care. COS- New order written to update the plan of during survey. Patient 7: The patient has Humalog PRN and insulin pen daily for DM2. Diabetes listed as a related diagnosis. No evidence of problems, goals, and interventions related to DM/Endocrine on the current plan of care. COS - New order written to update the plan of care during survey. Patient 12: The medical record indicated that the patient/caregiver accepted social services at the time of admission. The plan of care has active orders for the social worker to visit monthly. No evidence of problems, interventions, and goals related to social services included in the current plan of care. COS - New order written to add social services to the plan of during survey.

Upon patient record review, 3 of 19 (Patient #5,6,9) 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 5: The RN documentation indicated that the patient was using oxygen at 4LNC and 2.5LNC. The active medication list has an order for oxygen 2LNC PRN for shortness of breath. No evidence that the active medication list includes 4LNC or 2.5LNC and no evidence that the current order includes a titration order to increase when needed. COS-Active medication list updated during survey Patient 6: The medical record has an active order for acetaminophen rectal supp 650 mg PRN every 6 hours to given for constipation. COS - new order written to remove constipation as the PRN reason for use and add that it is to be used for mild pain. Patient 9: Active medication list has MiraLAX, Colace, and Dulcolax all listed as PRN for constipation. No evidence that the order included instructions on which medication to give first in the event of constipation. COS - new order written to add instructions during survey.

Upon patient record review, 2 of 19 (Patient #1,5) 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 1: The clinical documentation indicated that the patient currently uses a wheelchair due to weakness and impaired mobility. No evidence that the wheelchair was added to the current plan of care DME list. COS- Plan of care DME list updated during the survey. Patient 5: The medical record indicated that the patient used a rolling walker daily due to shuffled gait and impaired mobility. No evidence that the rolling walker was added to the current plan of care DME list. COS- Plan of care DME list updated during the survey.

Upon patient record review, 3 of 19 (Patient #4,5,12) 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. current level of care during survey. Patient 4: The clinical documentation indicated that the patient does not currently have an active wound. Active wound care orders remain on the current plan of care. COS - New orders written to remove wound care orders removed from the active plan of care during survey. Patient 5: The medical record indicated that patient requested to end aide services on 06/24/2025. Active orders for the aide to perform visits once a week remain on the current plan of care - new benefit period started on 07/08/2025. COS - new order written to remove the aide orders from the active plan of care during survey. Patient 12: The medical record indicated that patient requested to end chaplain services on 02/24/2025. Problems, interventions, and goals related to spiritual care remain on the current the plan of care - new benefit period started on 05/22/2025. COS - new order written to remove the spiritual care plan from the plan of care during survey.

Upon patient record review 5 of 19 (Patient #5,6,7,8,9) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient 5: The RN documentation indicated that the patient/caregiver accepted volunteer services at the time of admission. No evidence that follow-up occurred past the initial note entered by the VC which stated "Accepts volunteer services. Placed on the list for next available volunteer." Second benefit period started on 08/01/2025. Patient 6: The RN documentation indicated that the patient/caregiver accepted volunteer services at the time of admission. No evidence that follow-up occurred past the initial note entered by the VC which stated "Accepts volunteer services. Placed on the list for next available volunteer." Second benefit period started on 08/01/2025. Patient 7: The RN documentation indicated that the patient/caregiver accepted volunteer services at the time of admission. No evidence that follow-up occurred past the initial note entered by the VC which stated "Accepts volunteer services. Placed on the list for next available volunteer." Patient 8: The medical record indicated that the patient/POA accepted volunteer services at the time of admission on 2/03/2025. No evidence of volunteer coordination follow-up or that a visit was completed by a volunteer at the time that the chart was surveyed. Patient 9: The RN documentation indicated that the patient/caregiver accepted volunteer services as the time of admission. No evidence that follow-up occurred past the initial note entered by the VC which stated "Accepts volunteer services. Placed on the list for next available volunteer."

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient visit #2: Hospice aide used book bag for medical equipment and supplies. At the start of the visit, the aide placed her book bag on the facility floor without any barrier.

Upon patient record review, 3 of 19 (Patient #2,4,6) 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 2: The clinical documentation indicated that the patient has a related diagnosis of dysphagia and was identified as a risk for aspiration. No evidence that the aide plan of care included instructions for related risk for aspiration. COS - new order written to add to those instructions to the aide plan of care during survey. Patient 4: The aide plan of care includes instructions for patient to take a bath or shower 3 times a week patient was not cognitively able to choose per diagnosis and baseline confusion. COS - new order written to update aide plan of care during survey. Patient 6: The aide plan of care includes task to "change linens when soiled". No evidence that a frequency was included. COS - new order written to add frequency to linen changes on the aide plan of care during survey.

Upon patient record review 1 of 19 (Patient #10) 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 10: The aide plan of care included instructions to notify the RN when task are refused by the patient. The patient refused task on visits that occurred on 07/15 (shampoo), 07/18 (all task refused), 07/22 (nail care), 07/23,07/24, 07/30, 08/06 (shave). No evidence that the aide notified the RN that the task was refused.

Upon patient record review 3 of 19 (Patient #8,13,14) 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 8: No evidence that a registered nurse made an aide supervisory visit every 14 days between 04/23/25- 05/09/25 (16 days) and 05/20/2025-06/14/2025 (15 days). Patient 13: No evidence that a registered nurse made an aide supervisory visit every 14 days between 02/05/25- 04/01/25 (23 days) and 05/28/2025-06/17/2025 (22 days), 06/17/2025-07/09/2025 (22 days), and 07/22/2025-08/06/2025 (15 days). Patient 14: No evidence that a registered nurse made an aide supervisory visit every 14 days between 12/30/25-01/29/25 (30 days) again between 03/06/2025-04/02/2025 (16 days), 05/13/2025 - 07/15/2025 (64 days), and again between 07/15/2025- 08/06/2025 (22 days).

Upon patient record review, 1 of 19 (Patient #2) did not evidence that each patient record contains physician orders. Patient 2: The medical record contains an out of hospital DNR that is missing a signature date by the medical director.

Upon patient record review, 1 of 19 (Patient #13) 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 13: The RN documentation included supervisory for the LVN on 12/26/2024 and 01/02/2025. No evidence that the LVN completed a visit until 02/14/2025.

Upon patient record review, 1 of 19 (Patient #2) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 2: The plan of care has volunteer frequency ordered as twice a month for the months of Feb/March/April 2025. No evidence that the patient received 2 visits for the months of February 2025, March 2025, or April 2025. No evidence that the visit was missed at the request of the family or that an order was received to change the visit frequency for the month.

Upon patient record review 1 of 14 (Patient #7) 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 #7: Although the patient had a start of care date of 6/14/2022, the Social Work evaluation was not conducted until 6/20/2022.

Upon patient record review, 5 of 14 (Patients #3, 4, 6, 7, 8) 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: The medication profile listed Pyridium as needed and Hydrocodone every 4 hours PRN. There was no indicator listed for the PRN medications. Patient #4: The medication profile listed Hydromorphone every hour PRN. There was no indicator listed for the PRN medication. Patient #6: The medication profile listed Hydrocodone PRN. There was no indicator listed for the PRN medication. Patient #7: The medication profile listed "Novolog 1-5 units daily as directed". There were no specific directions listed on how to administer the Novolog. Patient #8: The medication profile listed Advil and Albuterol PRN. There was no indicator listed for the PRN medications.

Upon client record review, 7 of 14 (Patients #1, #2, #4, #6, #7, #8 and #10) did not have evidence that the IDG ensured that the care and services were provided in accordance with the plan of care. Patient #1: Orders for nursing frequency of 2x week. There was no evidence of second visit during the week of 5/29/2022 and there were no nursing visits for the week of 7/10/2022. Patient #2: Orders for a nursing frequency of 1x week. There was no evidence of nursing visits for the weeks of 6/19/2022 and 6/26/2022. During the nursing visit conducted on 6/12/2022, the nurse instructed the patient to decrease the Lasix from 40 to 20, and to hold the medications; Lisinopril and Carvedilol. There was no documentation of orders for the medication changes. Patient #4: Orders for a nursing frequency of 2x week. There was no evidence of second visit during the weeks of 6/19/2022 and 6/26/2022. Patient #6: Orders for a nursing frequency of 1x week and monthly Social worker and Chaplain visits. There was no evidence of nursing visits during the weeks of 6/26/2022 and 7/3/2022. There was no evidence of Social Worker and Chaplain visit during the month of July. Patient #7: Orders for volunteer frequency of 1x week. There was no documentation to indicate the Volunteer Services had started as of the Survey date. Patient #8: Orders for volunteer frequency of 1 x week. There was no documentation to indicate the Volunteer Services had started as of the Survey date. Patient #10: Orders for wound care to clean the wound and cover with xeroform, dressing. On a visit dated 4/28/2022, the nurse documented, "wound care with normal saline and leave open to dry" There was no order for the change in wound care.

Upon patient record review, 2 of 2 applicable (Patients #13 and #14) 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 Patients #13 and #14: Although mailings were going out to the bereaved, there was no indication the mailings and the frequency of the mailings were a part of the Bereavement Plan of Care.

Upon personnel record review, 1 of 1 applicable (Personnel #7) 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. Patient #7: There was no documentation to indicate the competency assessment was performed by the Aide with a patient or a psuedo patient.

Upon patient record review 4 of 12 applicable (Patients #4, #5, #7, #8) 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 #4: The Aide Care Plan directed the Aide to provide ..."perineal care, pivot with transfers and assist with ambulation..." There was no documentation to indicate those services were provided by the Aide on the visit conducted on 7/22/2022. Patient #5: The Physician orders included an Aide visit frequency of 2 x 1 week and 5 x week. There was no documentation to indicate the second visit was conducted during the first week. Starting on 6/19/2022, the Aide frequency went to 3 x week. There was no Physician order for the change in frequency. Patient #7: The Aide Care Plan directed the Aide to provide ...shower, shampoo and shave on Monday, Wednesday and Friday and to brush teeth every visit. (a) On Monday, (6/20/2022) the Aide documented that the shave was "not required". (b) On Friday, (6/24) and Wednesday, (7/6/2022) the Aide documented that the shampoo was "not required". (c) On Thursday, (6/23) and Wednesday, (7/6) the Aide documented that brushing the teeth was "not required". Patient #8: The Physician orders included an Aide visit frequency of 2 x week. There was no documentation to indicate the second visit was conducted during the week of 7/24/2022.

Upon personnel record review, 1 of 13 applicable (Personnel #4) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #4: There was no documentation to indicate a Competency Assessment had been conducted. It was a self-assessment only.

Upon client record review, 1 of 1 applicable (Patient #10) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility.

Upon client record review, 1 of 3 applicable (Patient #12) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #12: There was no documentation in the Clinical Record to indicate the discharge summary was sent to the Attending Physician.

Upon patient record review, 1 of 13 (Patient #4) did not have evidence that if a drug order is verbal or given via an electronic transmission, it is given to a Registered Nurse, Nurse Practitioner, pharmacist, physician or other licensed individuals as designated by state regulations. The person receiving the order records and signs it immediately and has the prescribing person sign it in accordance with state and federal regulations. Patient #4: On the nursing visit conducted on 7/27/2022, the nurse documented ..."MD called and Nitro ordered." There was no Physician order listed for the Nitro.