Every finding on record at Family Home Health Services, Inc

Upon patient record review, 1 of 19 (Patient #11) did not have evidence that the patient has received effective pain management and symptom control from the hospice for conditions related to the terminal illness. Patient 11: There is not evidence of effective pain management and symptom control by the hospice. The SN documented on 7/24/25 assisted SN with dressing change. Wounds were "pre-medicated but still hollered throughout dressing change. Toes black, necrotic. All areas cleansed and redressed". Corrected on site with updated POC.

Upon patient record review, 16 of 19 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,and 16) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patients 1-16 did not have evidence in the comprehensive assessment of documentation of the imminence of death.

Upon patient record review, 8 of 19 (Patient # 1, 3, 4, 5, 6, 7, 10, and 12) 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: Patient 1: Facility medication profile contains orders for Ferrous sulfate, Magnesium, Melatonin, Memantine, Mirtazapine, Polyethylene Glycol, and zinc not on agency medication profile. Corrected on site with updated profile. Patient 3: Agency medication profile contains orders for K-Chlor not present on facility medication profile. Facility medication profile contains orders for Benadryl, Bumex, Calcium Carbonate not present on the agency medication profile. Corrected on site with updated profile. Patient 4: Facility medication profile contains orders for Aricept and Norco that are not present on agency medication profile. Agency medication profile contains orders for Biscodyl and Xarelto not present on facility medication profile. Corrected on site with updated profile. Patient 5: The updated medication list contains an order for Dextran eye drops with no specifics for which eye to administer. Corrected on site with updated profile. Patient 6: The medication list contains orders for Acetaminophen 325 mg 2 tabs every 6 hours and 650 mg rectal suppositories every 4 hours with no limit to not exceed 4 grams in 24 hours. Corrected on site with updated profile to include 4 gram dose limit in 24 hour period. Patient 7: The initial medication profile on 6/19/25 contains orders for Acetaminophen 325 mg 2 tabs every 4 hours and 650 mg rectal suppositories every 4 hour with no limit to not exceed 4 grams in 24 hours. Corrected on site with updated profile to include 4 gram dose limit in 24 hour period. Patient 10: The initial medication profile contains orders for Acetaminophen orders for 500mg 2 tabs every 8 and 650mg rectal suppository every 4 hours with no limit to not exceed 4 grams in 24 hours. Corrected on site with updated profile to include 4 gram dose limit in 24 hour period. Patient 12: The updated medication list contains orders for Acetaminophen 325 mg 2 tabs q 6 hours and 650 mg rectal suppositories every 4 hours with no limit to not exceed 4 grams in 24 hours. Corrected on site with updated profile to include 4 gram dose limit in 24 hour period.

Upon patient record review, 8 of 19 (Patient # 1, 3, 4, 5, 6, 7, 10, 12) 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: Facility medication profile contains orders for ferrous sulfate, Magnesium, Melatonin, Memantine, Mirtazapine, Polyethylene Glycol, and zinc not on agency medication profile. Corrected on site with updated orders. Patient 3: Agency POC/medication profile contains orders for K-Chlor not present on agency POC/med profile. Facility POC/Medication profile contains orders for Benadryl, Bumex, Calcium Carbonate. Corrected on site with updated medication orders and updated POC. Patient 4: Facility POC contains orders for Aricept, Norco not present on agency POC. Agency medication profile contains orders for Biscodyl, Donepezil, and Xarelto not present on agency POC. Corrected on site with updated medication orders and updated POC. Patient 5: The updated POC contains an order for Dextran eye drops with no specifics for which eye to administer. Corrected on site with updated plan of care. Patient 6: The medication list contains orders for Acetaminophen 325 mg 2 tabs every 6 hours and 650 mg rectal suppositories every 4 hours with no limit to not exceed 4 grams in 24 hours. Corrected on site with updates to include limit of 4 grams per 24 hour period. Patient 7: The initial medication profile on 6/19/25 contains orders for Acetaminophen 325 mg 2 tabs every 4 hours and 650 mg rectal suppositories every 4 hour with no limit to not exceed 4 grams in 24 hours. Corrected on site with updated POC. Patient 10: The initial medication profile contains orders for Acetaminophen orders for 500mg 2 tabs every 8 and 650mg rectal suppository every 4 hours with no limit to 4gms in 24 hours. Corrected on site with updated POC. Patient 12: The updated medication list contains orders for Acetaminophen 325 mg 2 tabs q 6hr and 650 mg RS every 4 hours with no limit to 4 grams in 24 hours. Corrected on site with updated POC.

Upon patient record review, 1 of 19 (Patient # 6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 6: SN documents on 8/24/25 "flushing foley and draining properly." There is no evidence of foley care orders on POC. Corrected on site with updates to POC.

Upon patient record review 1 of 19 (Patient #11) 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 11: 7/22/25 SN documentation reflects patient with complicated grief patient told SN she "had been shot in her eye. Nurse clarified if injection or gun and patient said gun. Staff confirms that patient had been shot and that her sister was shot and killed in the not too distant past." There is not evidence of further discussion regarding complicated grief in IDG or referral made to other counseling services or community agencies.

Upon patient record review, 2 of 19 (Patient #7, 10) did not have evidence in the patient record that hospice aide assignments and duties are: Patient 7: The Aide POC contains orders for both shower and bed bath options. Patient lacks cognitive ability to determine bathing preference. Corrected on site with updates to Aide POC. Patient 10: The Aide POC at SOC 8/7/25 does not include any tasks for aide to complete during aide visits except for assist with shower. SN documents in comprehensive assessment at SOC the plan for aide services and "patient is chairbound; aide services for personal care, hygiene and ADLs will be provided." Corrected on site with updates to Aide POC.

Upon patient record review 1 of 19 (Patient # 5) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 5: Aide POC indicates bathing tasks to include one shower weekly and one partial bath weekly. Aide documentation the week of 7/27/25 indicate a shower was completed at each visit and no partial bath was given. Corrected on site with updated orders for POC.

Upon patient record review 1 of 19 (Patient # 5) 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 5: There is not evidence of aide supervisory visit completed by the RN for the aide between the dates of 7/2/25 and 8/14/25.

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. No evidence that the agency utilized volunteers for at least 5% of the total patient care hours in 2024. The total usage of volunteers for 2024 was 1.0%.

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: On 8/27/25, the skilled nurse prn visit is completed and skilled nurse documents "supervisory visit for LPN completed and name of nurse being evaluated is her own name."

Upon patient record review, 5 of 19 (Patient # 1, 2, 4, 11, 13) 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 1: Facility POC contains orders for Cath 18Fr 30cc balloon may change bag and catheter PRN and agency 7/23/25 POC does not show evidence of Foley Cath orders and care instructions. Corrected on site with updates to POC. Patient 2: Facility POC contains orders for heel boot and xeroform gauze apply to left elbow topically every evening and PRN not present on agency POC. Corrected on site with updated wound care orders and POC. Patient 4: Initial POC on 4/1/25 contains an order for Xarelto with no risk for bleeding noted on updated POC 6/15/25. Corrected on site with updated POC. Patient 11: SN documents in SOC comprehensive assessment on 2/2/25, " Patient has 5 wounds" and indicates locations of the 5 wounds. Initial POC does not include what wound care should be provided to each wound on 2/2/25 POC. Corrected on site with updated POC. Patient 13: Initial POC on 8/7/25 contains order for coumadin with no risk for bleeding noted on POC. PRN visit completed 8/24/25 SN documents “fell a few days ago on coumadin, sent to ER for lethargy. MD spoke with family and sent back to SNF for comfort care.” Patient expired on 8/28/25.

Upon patient record review, 1 of 19 (Patient # 11) 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 11: Order received on 4/4/25 clean with NS daily, apply bacitracin, cover with gauze and ABD dressing. No specifics on order where, how often, and who will complete dressing change. In facility, no indication on who will provide care of the wounds. Corrected on site with updated POC.

Upon patient record review, 3 of 13 (Patients #1, 4, and 12) did not contain a complete/comprehensive Medication Profile: Patient #1: The record reflected that the patient had an order for, "Oxygen 2-5 liters as needed SOB." This was not included on the Medication Profile. Patient #4: The IDG POC dated 07/13/22 reflects a Morphine allergy. This was not included on the Medication Profile. Patient #12: The SOC assessment reflected that the patient had an order for, "Oxygen 5 liters continuous." This was not included on the Medication Profile.

Upon patient record review, 2 of 13 (Patients #4 and 10) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, specifically: A detailed statement of both the scope and frequency of services necessary to meet the specific patient and family needs: Patient #4: SOC was 06/10/22. The IDG Plan(s) of Care dated 06/22/22, 07/01/22, and 07/13/22, all ordered Chaplain visits at a visit frequency of, "3 p.r.n. visits", without an established baseline visit frequency. Patient #10: The POC dated 05/04/22 ordered Chaplain visits at a visit frequency of, "3 p.r.n. visits", without an established baseline visit frequency.

Upon patient record review, 6 of 13 (Patients #1, 2, 4, 6, 8, and 10) did not contain evidence that the Plan of Care included all care/services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments: Patient #1: During Surveyor-attended 07/20/22 visit at SNF, the patient was observed to have gauze wrappings around his bilateral ankles/feet. There was no information regarding this wound/compromised skin area intervention on the Hospice POC. Patient #2: During Surveyor-attended 07/20/22 visit at SNF, a pole with bag of enteral feeding, a g-tube and wound care observed to right hip was noted. The Hospice has no Physician orders for the g-tube site care, tube feeding and wound care or who is providing these treatments hospice or facility. Patient #4: The 07/17/22 SN visit noted six wounds, five open and one closed. The Hospice POC did not contain any Physician-ordered details for any of these wound care procedures or who is responsible for providing these. Patient #6: The SN visit on 07/05/22 noted, "Abdominal wound appears to be healing." The Hospice POC did not contain any Physician-ordered details for a wound care procedures or who is responsible for providing these. Patient #8: The SOC RN assessment notes, "Wound care already completed by Facility nurse. Dressing in place without drainage. The Hospice POC did not contain any Physician-ordered details for a wound care procedures or who is responsible for providing these. Patient #10: A 04/21/22 SOC order listed Diet as "G-tube". The order did not include tube feedings. The SOC Physician CTI noted three different wounds buttocks, sacral and right and left heels. The Hospice POC did not contain any Physician-ordered details for such wound care procedure(s) or who is responsible for providing these.

Upon patient record review, 2 of 2 applicable (Patients #12 and 13) did not contain evidence that the Hospice had offered post-death Bereavement Counseling that includes: The development of a patient-specific, individualized, Bereavement Plan of Care, that notes the kind of Bereavement services to be offered, and the scheduled frequency/time-frame for such service delivery. There was no evidence of a patient-specific, individualized Bereavement POC for each patient, which is filed in the patient's clinical record.

Upon personnel record review, 1 of 1 applicable Aide (Personnel #8) did not contain evidence of an Aide Skills Competency Evaluation, which included all CMS-required content. An Aide Skills Competency was conducted on 02/21/22. However, the following skill set was not evaluated for competence: The physical, emotional, and developmental needs of, and ways to work with, the populations served by the Hospice.

Upon patient record review, 2 of 12 applicable (Patients #1 and 11) did not contain evidence that a skilled professional had established a Hospice Aide Plan of Care/Assignment Sheet, which was individualized, and indicated what tasks are to be done by the Aide, and the frequency of such tasks; along with any other pertinent patient information. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable: Patient #1: The record reflected that the patient had a D.N.R. order. This information was not included on the Aide POC. The SOC was 07/08/2022. At the date of survey 07/20/22, the Aide POC continued to assign: 1) Bed Bath 1x per week; and 2) Shower 1x per week. During the Surveyor-attended home visit on 07/20/22, the RN and Aide clarified that the 'shower' should no longer be on the POC. The Aide reported that she has always provided a bed bath for this patient. The Aide POC had not been updated. Patient #11: The record reflected that the patient had a D.N.R. order. This information was not included on the Aide POC.

Upon patient record review 1 of 13 (Patient #9) 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 #9: Each IDG POC from SOC 6/13/22 to 07/13/22 all included Aide visits at a frequency of 2x per week. Aide services were never initiated for this patient.

Upon patient record review, 2 of 2 applicable (Patients #10 and 11) did not contain evidence that the Discharge Summary included all CMS-required information: Patients #10 and 11: These DC Summaries did not include: • A summary of the patient's stay, including treatments, symptoms and pain management • The patient's current Plan of Care • The patient's latest Physician orders

Upon patient record review, 2 of 13 (Patients #1 and 3) did not contain evidence that the Interdisciplinary Group, as part of the review of the Plan of Care, had determined the ability of the patient and/or family/caregiver to safely self-administer drugs and biologicals to the patient in his or her home setting. If the patient and/or family are not capable of safely administering drugs and biologicals, the Hospice must address this issue in the patient's plan of Care.

Upon patient record review, 13 of 13 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13) did not contain documented evidence that the Hospice's written policies and procedures for managing the disposal of controlled drugs had been provided and discussed with the patient/caregiver.

Upon SNF contract review, 1 of 1 applicable (Alden Poplar Creek/SNF) did not contain a written provision that it is the Hospice's responsibility to provide services at the same level, and to the same extent, as those services would be provided if the SNF Resident were in his or her own home.

Upon SNF contract review, 1 of 1 applicable (Alden Poplar Creek/SNF) did not contain a written provision stating that the Hospice shall report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property, by anyone unrelated to the Hospice, to the SNF 'Administrator' within 24 hours of the Hospice becoming aware of such alleged violation.

Upon patient record review, 1 of 13 applicable (Patient #7) did not contain evidence that the Hospice Plan of Care identified 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. Verbal order(s) were obtained by Hospice on 05/10/22 for: 1) Apply Zinc Oxide to right inner buttock BID and p.r.n. soiling; and 2) Apply Medi-honey to to right inner buttock BID and p.r.n. soiling." This is not a complete order as it does not clarify 'who', the Hospice nurses or the SNF nurses are responsible for this BID wound intervention.