Every finding on record at Envoy Hospice, LLC

Upon patient record review, 4 of 19 (Patient #1,#3,#8,#10) 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:The medication profile includes an entry for Isosource 1.5 calorie, 1 carton 3 times daily via G tube. There is no evidence on the medication profile that the entry includes a specific amount for administration. The medication profile includes an entry for MiraLAX 17 mg po daily for constipation. There is no evidence on the medication profile that the entry includes a type and amount of diluent for administration. COS Patient 3:The medical record includes an entry on 5/10/24 that the patient uses Bengay over the counter for pain control. There is no evidence on medication profile on an entry for Bengay. COS Patient 8:The medication profile includes an entry for Glucerna 1.5 calorie, 1 carton 3 times daily via G tube. There is no evidence on the medication profile that the entry includes a specific amount for administration. COS Patient 10:The medication profile includes an entry on 5/9/24 for Nystatin external powder ordered x7 days. The entry remains on medication profile on 5/30/24. COS

Upon patient record review, 2 of 19 (Patient #1,#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 1 and 13:The medical record contains nursing documentation of oxygen 2-4 liters per minute as needed for shortness of breath. There is no evidence on the plan of care of problems, goals and interventions for the use, management and safety for oxygen.

Upon patient record review, 3 of 19 (Patient #1,#3,#8) 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:The plan of care includes an order for Isosource 1.5 calorie, 1 carton 3 times daily via G tube. There is no evidence in the order of a specific amount for administration. The plan of care includes an order for MiraLAX 17 mg po daily for constipation. There is no evidence on the plan of care that the order includes a type and amount of diluent for administration. Patient 3:The plan of care includes an entry on 5/10/24 that the patient uses Bengay over the counter for pain control. There is no evidence on plan of care on an entry for Bengay. Patient 8:The plan of care includes an entry for Glucerna 1.5 calorie, 1 carton 3 times daily via G tube. There is no evidence on the plan of care that the entry includes a specific amount for administration.

Upon client record review, 1 of 19 (Patient #9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 9:The nursing plan of care included a problem of pain and comfort with a coordination intervention of assessment of pain during SN visits. There is no evidence that the RN assessed for pain during the home visit with the surveyor on 5/29/24.

Upon Home Visit, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 9: Per the policy of bag technique of the agency, the clinician should sanitize their hands prior to examining the patient. During the home visit with the surveyor on 5/29/24, the RN donned gloves without sanitizing hands prior to examination of the patient.

Upon patient record review, 2 of 19 (Patient #9,#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 9:The aide plan of care includes the tasks of Bed Bath and change linens. There is no evidence of a frequency for provision of these tasks included on the aide plan of care. Patient 13:The aide plan of care includes the tasks of empty colostomy bag, turn and reposition and bed bath. There is no evidence of a frequency for provision of these tasks included on the aide plan of care.

Upon patient record review, 1 of 19 (Patient #9) 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 9:The medical record contains nursing documentation of oral antibiotic therapy beginning 5/22/24 for 7 days for an upper respiratory infection. The documentation of the adverse event note on 5/22/24 noted that the antibiotic was started on 5/20/24, per the facility. The clinical director confirmed that the antibiotic therapy began on 5/22/24, not 5/20/24.