Every finding on record at Envoy Hospice, LLC

Upon patient record review 1 of 19 (Patient #12) 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 12: Patient admitted 7/18/23. Spiritual care assessment not completed until 7/24/23. There is no evidence of patient request for later visit.

Upon patient record review, 8 of 19 (Patient #2,3,4,5,6,11,12,13) 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 2:Nystatin External Powder found on medication list with the instructions, "apply a small amount of powder twice per day as directed". There are no further instructions indicating site of application. Patient 3: Amoxicillin present on medication list twice daily x 7 days beginning 12/28/23. Medication continues to show as active even though medication should of been discontinued around 1/3/24. Further, Acetaminophen every 6 hours as needed for pain 4-8/10 and Hydrocodone/Acetaminophen every 4 hours as needed for pain 4-6/10 are both present with no clear instructions on when to administer which medication when pain is rated between 4-6. Verified with staff that Acetaminophen should be indicated for pain rating 1-4/10. Patient 4: Acetaminophen 500mg 2 tablets as needed every 8 hours for pain or fever and Tylenol extra strength 500mg 2 tablets as needed every 8 hours for pain or fever are both present on the medication list resulting in a duplication of active ingredient of medication. Further, Tramadol 50mg every 8 hours as needed and Oxycodone 5mg every 4 hours is listed with no clear indications as to when to administer these medications for pain versus other prescribed medications. Patient 5: Lorazepam 0.5mg 1-2 tablets as needed every 4 hours present on medication list with instructions of, "Take 1-2 every 4 hours by mouth as needed for anxiety/agitation." There is no evidence of further instruction when to administer 1 versus 2 tablets for symptom management. Patient 6: Norco 5-325 by mouth 1 tablet every 4-6 hours as needed for pain is present on medication list. There is no evidence of further instruction on when to administer Norco related to severity/intensity versus Morphine Sulfate solution that is present starting with a pain rating of 1-3/10 or Acetaminophen rectal suppository as needed every 6 hours pain or fever that, along with the Norco, gives no further indication of appropriateness of administration based on pain intensity/severity. In addition, Acetaminophen 650mg rectal suppository every 6 hours for fever is present with a start date of 5/27/24 making the aforementioned Acetaminophen suppository a duplication of medication as it was initiated 6/5/24. Patient 11: Acetaminophen 325 mg (2 po) every 6 hours as needed "pain or fever", Acetaminophen 650mg rectal suppository every 6 hours as needed "pain or fever". The entry does not include a maximum dose of 4000mg daily. Patient 12: Dulcolax rectal suppository present on medication list with the instructions, "insert 1 suppository rectally daily as needed" with no indication for use of medication. Ondansetron 8mg every 8 hour listed with no further instruction on indication for use. Tramadol 50mg PRN every 6 hours "for pain" and Tylenol 325mg 2 tablet "PRN every 4 hours as needed" present with no further instruction on when to administer each medication related to pain intensity or severity. No evidence found of instruction on when to administer one pain medication versus the other based on intensity, severity, or unrelieved symptoms. Patient 13: Oxygen 2-4LPM prn, "nose" present with no further instructions related to route, whether NC or face mask.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 9 of 19 (Patient #1, 2, 3, 8, 9,10, 11, 13, & 14) 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: SN documentation reveals patient is a high fall with with a history of recurrent falls. The plan of care contains no safety measures, problem, interventions, or goals related to fall precautions. Patient 2: SN documentation reveals high fall risk with history of recurrent falls, decreased intake with diagnosis of dysphagia & anorexia, with use of supplemental drink, as well as use of Oxygen as needed. There are no problems, interventions, or goals related to Fall precautions, Nutrition, or the use of Oxygen and safety risks. Patient 3: Plan of Care goals for hospice general, pain, skin/wound, respiratory, cardiovascular, GI/GU, musculoskeletal, and Covid emergency plan all restate the goal after "AEB:" to indicate the measure of goal progress/management. "Goal: Patient/family establishes desired pain control- AEB patient establishes desired pain control.", "Patient cardiac symptoms will be managed - AEB patients cardiac symptoms will be managed." Problems/Goals/Interventions not individualized. Patient 8: Documentation reveals diagnosis of seizure disorder. No evidence of seizure precautions as safety measures found on plan of care. Patient is a resident of SNF however, plan of care does not reflect whether hospice staff or facility staff is to perform interventions nor does it specify who, pt/cg/facility are to be educated. Patient 9: MSW problem open with interventions and goals associated. The interventions do not delineate who is to perform these tasks and whether it should be/is the MSW as the problem name infers, or if these psychosocial interventions should be conducted by the visiting SN. There is no MSW frequency listed on the POC. It is unclear what psychosocial need the patient has related to visiting staff and frequency and if the proper staff is conducting visits and enacting/aware of needed interventions. Patient 10 & 11: Oxygen in use per documentation. No evidence found of Oxygen precautions in place per patient Safety Measures. Patient 13: SN documentation reveals patient is a high fall with with a history of recurrent falls. The plan of care contains no safety measures, problem, interventions, or goals related to fall precautions. Also, SN documentation reflects poor appetite with decreased intake to bites to 50% of meals 2-3 times daily with a thin, frail appearance. No evidence of nutritional problem, interventions, or goal on plan of care. Patient 14: Plan of care contains problem, intervention, and goals related to seizure precautions. However, seizure precautions is not specified under general clinical safety precautions for all disciplines. General clinical safety precautions contain aspiration precautions but there are no associated problem, interventions, or goal on the patient plan of care.

Upon patient record review, 10 of 19 (Patient #1, 4, 6, 7 8, 9, 10, 11, 12, & 19) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Utilizing the same weekly/monthly visit frequency consistently (per discipline/per patient) coupled with broad PRN visit availability does not reflect detailed scope and frequency of visits needed to ensure patient individual needs are met for the following: Patient 1: SN visit frequency is 1x weekly and 10 PRN, MSW visit frequency is once monthly and 7 PRN per the patient plan of care. Patient 4: SN visit frequency is 1x weekly and 7 PRN per the patient plan of care. Patient 6: SN visit frequency is 1x weekly and 7 PRN, MSW visit frequency is once monthly and 6 PRN per the patient plan of care. Patient 7: SN visit frequency is 1x weekly and 10 PRN, MSW visit frequency is once monthly and 7 PRN, & SC is 1x monthly and 7 PRN per the patient plan of care. Patient 8: MSW visit frequency is 1x monthly and 7 PRN, and SC is 1x monthly and 7 PRN per the patient plan of care. Patient 9: SN visit frequency is 1x weekly and 9 PRN per the patient plan of care. Patient 10: SN visit frequency is 3x weekly and 8 PRN, MSW visit frequency is once monthly and 7 PRN, & SC is 1x monthly and 7 PRN per the patient plan of care. Patient 11: SN visit frequency is 1x weekly and 7 PRN, MSW visit frequency is once monthly and 7 PRN, & SC is 1x monthly and 10 PRN per the patient plan of care. Patient 12: SN visit frequency is 1x weekly and 7 PRN, MSW visit frequency is 4x monthly and 7 PRN, & SC is 2x monthly and 7 PRN per the patient plan of care. Patient 19: SN visit frequency is 1x weekly and 7 PRN, and SC is once monthly with 8 PRN per the patient plan of care.

Upon patient record review, 8 of 19 (Patient #2,3,4,5,6,11,12,13) 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 2: Incomplete orders for Nystatin External Powder found on plan of care with the instructions, "apply a small amount of powder twice per day as directed". There are no further instructions indicating site of application. Patient 3: Incomplete orders for Amoxicillin present on plan of care twice daily x 7 days beginning 12/28/23. Medication continues to show as active even though medication should of been discontinued around 1/3/24. Further, Acetaminophen every 6 hours as needed for pain 4-8/10 and Hydrocodone/Acetaminophen every 4 hours as needed for pain 4-6/10 are both present with no clear instructions on when to administer which medication when pain is rated between 4-6. Verified with staff that Acetaminophen should be indicated for pain rating 1-4. Patient 4: Incomplete orders for Acetaminophen 500mg 2 tablets as needed every 8 hours as needed for pain or fever and Tylenol extra strength 500mg 2 tablets as needed every 8 hours as needed for pain or fever are both present on the plan of care resulting in a duplication of active ingredient of medication. Further, Tramadol 50mg every 8 hours as needed and Oxycodone 5mg every 4 hours is listed with no clear indications as to when to administer these medications for pain versus other prescribed medications. Patient 5: Incomplete orders for Lorazepam 0.5mg 1-2 tablets as needed every 4 hours present on plan of care with instructions of, "Take 1-2 every 4 hours by mouth as needed for anxiety/agitation." There is no evidence of further education on when it is indicated to administer 1 versus 2 tablets for symptom management. Patient 6: Incomplete orders for Norco 5-325 by mouth 1 tablet every 4-6 hours as needed for pain is present on plan of care. There is no evidence of further instruction on when to administer Norco related to severity/intensity versus Morphine Sulfate solution that is present starting with a pain rating of 1-3/10 or Acetaminophen rectal suppository as needed every 6 hours pain or fever that, along with the Norco, gives no further indication of appropriateness of administration based on pain intensity/severity. In addition, Acetaminophen 650mg rectal suppository every 6 hours for fever is present with a start date of 5/27/24 making the aforementioned Acetaminophen suppository a duplication of medication as it was initiated 6/5/24. Patient 11: Incomplete orders for Acetaminophen 325 mg (2 po) every 6 hours as needed "pain or fever", Acetaminophen 650mg rectal suppository every 6 hours as needed "pain or fever". The entry does not include a maximum dose of 4000mg daily. Patient 12: Incomplete orders for Dulcolax rectal suppository present on plan of care with the instructions, "insert 1 suppository rectally daily as needed" with no indication for use of medication. Ondansetron 8mg every 8 hour listed with no further instruction on indication for use. Tramadol 50mg PRN every 6 hours "for pain" and Tylenol 325mg 2 tablet "PRN every 4 hours as needed" present with no further instruction on when to administer each medication related to pain intensity or severity. No evidence found of instruction on when to administer one pain medication versus the other based on intensity, severity, or unrelieved symptoms. Patient 13: Incomplete orders for Oxygen 2-4LPM prn, "nose" present with no further instructions related to route, whether NC or face mask.

Upon patient record review, 3 of 19 (Patient #5, 7, & 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 equipment and supply needs. Patient 5, 7: Aide instructions and SN documentation reveal need for and use of wheelchair. DME is not listed on patient plan of care. Patient 9: Plan of Care reflects the name of the DME company providing equipment rather than actual equipment placed in home.

Upon patient record review, 1 of 19 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: SN frequency per plan of care once weekly. SN visits conducted 2x week the weeks of 3/24/24 and 4/5/24. SN visits conducted 3x weekly from the week of 4/14/24 to present.

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. Home visit #1: Staff member did not clean and disinfect hands after removing dressing material and prior to donning gloves. Gloves noted to be donned and doffed 3 times during wound care but hands were not disinfected between removal of dirty gloves and application of clean gloves. Home visit #2: Staff member did not clean and disinfect equipment after patient use and prior to returning to their nursing bag as required per Bag Technique policy 5.5b.

Upon patient record review, 1 of 19 (Patient #8) 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 8: Seizure precautions are indicated per diagnosis and nursing documentation but no evidence is found on aide instructions. Further, aide instructions contain the goal statement, " Patient/Family receives assistance with ADLs - AEB aide visits per frequency and on days patient refuses OR too weak to shower perform a bed bath." However, there is no clarification as to if patient is cognitively and functionally able to voice request for bed bath rather than shower. Further, there is no corresponding intervention to perform or document completion of a bed bath at the time of visit. There was unclear documentation of which type of bath to perform.

Upon patient record review 2 of 19 (Patient #5, 12) 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 5: Aide frequency 3x weekly. Week of 5/13/24, 2 visits were completed with no evidence of missed visit documented. Patient 12: Aide instructions state change linens-every visit, shower-every visit, shampoo-every visit. 9 of 24 visits, ranging from 5/2/24 to present has some or all of these mentioned tasks marked as, " NV- not required at this visit." This is not the same code used to indicate refusal by patient or caregiver. There is no further evidence found of whether this task "not being required" was a decision made by the CNA or if the patient or caregiver truly refused task or to otherwise explain why a task marked as necessary at each visit by the RN was not completed.