Every finding on record at Family Hospice, Ltd.

Upon patient record review 3 of 19 (Patient #6,10,14) 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 6: No evidence that the initial spiritual comprehensive assessment was completed within 5 days of admission. The patient was admitted on 03/20/25. The spiritual care assessment was completed on 3/31/25, 11 days after admission. Patient 10: No evidence that the initial spiritual comprehensive assessment was completed within 5 days of admission. The patient was admitted on 03/21/25. The spiritual care assessment was completed on 3/27/25, 6 days after admission. Patient 14: No evidence that the initial spiritual comprehensive assessment was completed within 5 days of admission. The patient was admitted on 03/05/25. The spiritual care assessment was completed on 3/11/25, 6 days after admission.

Upon patient record review, 4 of 19 (Patient #1,5,6,7) 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 RN documentation indicated that patient has oxygen at 2L at bedtime. No evidence that oxygen was added to the current medication list. COS- new order placed for oxygen at 2LNC PRN during survey. Patient 5: The RN documentation indicated that patient uses a BIPAP at 7L continuously. No evidence that BIPAP orders were added to the current medication list. COS - new order placed for CPAP during survey. Patient 6: The RN documentation indicated that patient has oxygen at 2L as needed at bedtime. No evidence that oxygen was added to the current medication list. COS - new order placed for oxygen at 2LNC PRN during survey. Patient 7: The current plan of care includes orders for Lorazepam 1mg tab PRN as needed for seizures. No evidence active medication profile included a frequency for the medication to be given. The RN documentation indicated that the patient used oxygen at 3-5L NC. The current medication profile has the oxygen flow rate ordered at 5-10L via NC. No evidence that the an order was received for 3LNC. COS - new order placed to update oxygen flow during survey.

Upon patient record review, 1 of 19 (Patient #6) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 6: The patient was admitted on 03/20/2025. No evidence that the initial bereavement risk assessment was completed within 5 days of admission. Assessment completed on 04/22/2025.

Upon patient record review, 2 of 19 (Patient #9,13) 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 Patient 9: No evidence that a RN comprehensive assessment was completed every 15 days between 06/26/2025 and 07/17/2025. 21 days between assessments. Patient 13: No evidence that a RN comprehensive assessment was completed every 15 days between 06/27/2025 and 07/19/2025. 22 days between assessments.

Upon patient record review, 1 of 19 (Patient #3) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. policy is for wounds to be measured weekly. Patient 3: The record indicates that patient developed cellulitis on 02/13/2025 that healed on 03/13/2025. No evidence that the wound was measured since the day it was first assessed by the RN. The record indicates that patient developed a wound to the left buttock on 04/23/2025. No evidence that the wound was assessed. The documentation reflects that the wound was active from 04/23/2025 - 05/27/2025. Gentiva policy is for wounds to be measured weekly.

Upon patient record review, 2 of 19 (Patient #8,14) 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 8: The documentation indicated that the patient has trouble swallowing and is a risk for aspiration. No evidence of problems, interventions, and goals related to safety/risk of aspiration. COS - Plan of care order written to add aspiration to the active plan of care during survey. Patient 14: The documentation indicated that the patient has trouble swallowing and is a risk for aspiration. No evidence of problems, interventions, and goals related to safety/risk of aspiration. COS - Plan of care order written to add aspiration to the active plan of care during survey.

Upon patient record review, 1 of 19 (Patient #5) 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. use. Physician order updated during the survey. Patient 5: The initial visit frequency for both the social worker and the spiritual care counselor was 1 PRN without a standing order on the initial evaluation order, order corrected once the disciplines completed their evaluations.

Upon patient record review, 4 of 19 (Patient #1,5,6,7) 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. medications and treatments. Patient 1: The RN documentation indicated that patient has oxygen at 2L at bedtime. No evidence that an order was received for oxygen. COS- new order placed for oxygen at 2LNC PRN during survey. Patient 5: The RN documentation indicated that patient uses a BIPAP at 7L continuously. No evidence that an order was placed for BIPAP. COS - new order placed for CPAP during survey. COS - new order placed for CPAP during survey Patient 6: The RN documentation indicated that patient has oxygen at 2L as needed at bedtime. No evidence that an order was received for oxygen. COS- new order placed for oxygen. COS - new order placed for oxygen at 2LNC PRN during survey. Patient 7: The current plan of care includes orders for Lorazepam 1mg tab PRN as needed for seizures. No evidence that the order included a frequency for the medication to be given. The RN documentation indicated that the patient used oxygen at 3-5L NC. The plan of care has the oxygen flow rate ordered at 5-10L via NC. No evidence that the an order was received for 3LNC. COS - new order placed to update oxygen flow 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 medical record indicated the patient has oxygen PRN available in the home. No evidence that oxygen was included on the current DME supply list. The current supply list included wound care supplies. No evidence that the patient has ever had a wound during time of service. COS - New order written to update the current DME and supply list during survey. Patient 5: The clinical documentation indicated that the patient uses a Hoyer lift due to altered mobility that is used for transfers. No evidence that a Hoyer lift was included on the current DME list. COS- New order written to update the current DME list.

Upon patient record review, 1 of 19 (Patient #14) 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. Patient 14: The medical record indicated that patient requested to end chaplain services on 05/28/2025. Problems, interventions, and goals related to spiritual care remain on the current the plan of care - new benefit period started on 07/12/2025. COS - new order written to remove the spiritual care plan from the plan of care during survey.

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 RN documentation indicated that the patient acquired a skin tear on 08/17 and that the nurse changed the bandage on 08/18/2025. No evidence that an order was received that contained specific wound care orders for the skin tear.

Upon patient record review 1 of 19 (Patient #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 9: An order for volunteer evaluation placed on 05/28/2025. The VC documented that there was no volunteers available at that time and that a follow-up will occur in 2 weeks. No evidence that the follow-up was completed at the time of survey.

Upon patient record review, 3 of 19 (Patient #17,18,19) 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 #17: No evidence that the bereavement plan of care was being followed. No evidence of post-death 2 week mailing was mailed within 2 weeks of the date of death. Patient died on 11/05/2024, sent on 12/23/2024. Patient #18: No evidence that the bereavement plan of care was being followed. Patient had 2 bereavement contacts. One was mailed a unable to contact letter. The other had a care plan for letters to be sent. No evidence of post-death 2 week mailing was mailed within 2 weeks of the date of death. Patient died on 10/04/2024, sent on 12/23/2024. No evidence that the 6 month letter was sent. Patient #19: No evidence that the bereavement plan of care was being followed. No evidence of post-death 2 week mailing was mailed within 2 weeks of the date of death. Patient died on 12/27/2024, no evidence that the mailing was sent.

Upon patient record review 1 of 19 (Patient #1) 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 1: No evidence that a registered nurse made an aide supervisory visit every 14 days between 07/15/25- 07/31/25 (16 days).

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. Agency volunteer hours for 2024 was 1.51%

Upon patient client record review, 1 of 19 (Patient #3) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 3: Legal representative elected to receive the notice of hospice Non-covered items, services, and drugs at the time of admission, 03/12/2025. No evidence that the addendum was furnished within 5 days of the request. The addendum was furnished on 03/27/2025.

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency. Corrected on site.

Upon patient record review, 4 of 13 (Patients #3,#5,#6,#7) 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 dated 12/18/21 documented Narcan 4mg/actuation nasal spray as needed for over sedation, without indication of number of actuations, frequency of delivery or instructions for actions if administration is ineffective. Corrected on Site. Patient #5 The Medication Profile dated 7/25/22 documented O2 6 liters per nasal cannula. The IDG notes dated 8/19/22 - 9/7/22 documented O2 on a 7L. Corrected on Site. Patient #6 The Medication Profile dated 7/14/22 documented Narcan 4mg/actuation nasal spray as directed for possible opioid overdose, without indication of number of actuations, frequency of delivery or instructions for actions if administration is ineffective. Corrected on Site. Patient #7 The Medication Profile dated 8/29/2022 documented Narcan 4mg/actuation nasal spray as directed for possible opioid overdose, without indication of number of actuations, frequency of delivery or instructions for actions if administration is ineffective. Corrected on Site.

Upon patient record review, 3 of 13 (Patients #3,#8,#9) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #3 The patient was admitted 12/18/21. The Bereavement Assessment was dated 2/15/22. Patient #8 The patient was admitted 1/7/22. The Bereavement Assessment was dated 4/14/22. Patient #9 The patient was admitted 4/1/22. The Bereavement Assessment was dated 4/8/22.

Upon patient record review, 4 of 13 (Patients #4,#7,#8,#10) 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 #4 The patient had an admitting diagnosis of hypertensive heart failure with a history/comorbidities of CHF, edema and dyspnea with minimal exertion without any evidence in the record of cardiac goals or interventions. Corrected on Site. Patient #7 The patient had an admitting diagnosis of Cerebral Atherosclerosis with a Dementia comorbidity without any evidence in the record of neurologic or dementia goals or interventions. Corrected on Site. Patient #8 The patient had an admitting diagnosis of Cerebral Atherosclerosis without any evidence in the record of neurologic goals or interventions. Corrected on Site. Patient #10 The patient had an admitting diagnosis of Cerebral Atherosclerosis with a Vascular Dementia comorbidity without any evidence in the record of neurologic or dementia goals or interventions. Corrected on Site.

Upon patient record review, 4 of 13 (Patients #3,#5,#6,#7) 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 #3 The Medication List dated 12/18/21 ordered Narcan 4mg/actuation nasal spray as needed for over sedation without indication of number of actuations, frequency of delivery or instructions for actions if administration is ineffective. Corrected on Site. Patient #5 The Medication List dated 7/25/22 ordered O2 6 liters per nasal cannula. The IDG notes dated 8/19/21 - 9/7/21 documented O2 on a 7L. Corrected on Site. Patient #6 The Medication List dated 7/14/22 ordered Narcan 4mg/actuation nasal spray as directed for possible opioid overdose, without indication of number of actuations, frequency of delivery or instructions for actions if administration is ineffective. Corrected on Site. Patient #7 The Medication List dated 8/29/2022 ordered Narcan 4mg/actuation nasal spray as directed for possible opioid overdose, without indication of number of actuations, frequency of delivery or instructions for actions if administration is ineffective. Corrected on Site.

Upon client record review, 2 of 13 (Patients #2,#12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2 POC dated 7/14/22 ordered discontinuance of Spiritual Care services. The record indicated a PRN spiritual care visit 7/27/22 and a routine spiritual care visit 8/19/22 without evidence of an order to resume Spiritual Care services. Patient #12 POC dated 1/6/22 ordered Volunteer services to begin 2/9/22. There was no evidence in the record that volunteer services were furnished.

Upon patient record review, 1 of 12 applicable (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 No bleeding precautions were evident in the Aide POC yet the patient was taking Eliquis. The Aide POC dated 7/6/22 ordered transfer from bed to chair and from chair to bed each visit. On 8/16/22 a notation was added within the notes of the Aide POC to discontinue these tasks each visit, however the Aide POC was not updated to reflect this change and the Aide continued to perform the task. Corrected on Site.

Upon patient record review 1 of 12 applicable (Patient #7) 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 #7 The Aide POC dated 6/30/22 ordered transfer to toilet and transfer to chair each visit. The Aide visit note dated 7/14/22 documented for each of these tasks “not needed this visit per frequency”.

Upon patient client record review, 2 of 13 (Patient #1 and #11) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #1 admitted 7/12/22, The Notification of Non-Covered Items, Services and Drugs was requested upon admission. The evidence in the record indicated that the notice was not furnished or signed until 7/18/22. Patient #11 admitted 7/13/22, The Notification of Non-Covered Items, Services and Drugs was requested upon admission. There is no evidence in the record that the notice was furnished.

Upon patient client record review, 4 of 13 (Patient #2,#3,#4,#6) 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 #2 There was evidence in the record of two Benefit Election Statements. The electronic Benefit Election Statement documented, "no I do not consent to having community homecare and hospice representatives perform the care coordination services which includes visiting me in any facility to which I might be admitted while receiving my health care needs from community home care and hospice". The paper Benefit Election Statement documented, "yes I do consent to having community homecare and hospice representatives perform the care coordination services which includes visiting me in any facility to which I might be admitted while receiving my health care needs from community home care and hospice". It was not determined which response was accurate. Patient #3 The SN visit note dated 12/18/21 documented, "O2 dependent for leaders L via nasal cannula" and "patient admitted routine home care/GIP at facility". Patient #4 The Volunteer visit note dated 8/23/22 was originally dated 8/10/22 with an incorrect correction of a single line drawn through the erroneous date without being initialed by the author. Patient #6 POC dated 7/14/22 ordered DNR. IDT notes 7/22, 8/5, 8/19, and 9/2 documented patient as a full code.

Upon patient record review, 1 of 1 applicable (Patient #3) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice's 24-hour on-call system • Hospice medication information specific to each patient • Hospice physician and attending physician (if any) orders specific to each patient Corrected on Site

Based on record review and interview, the facility failed to maintain and update the Emergency Preparedness manual (binder) with a current staff list and a current patient list. This deficient practice can delay the ability to offer continued patient care by not having a current staff list to contact to assist with patients and a current patient list to know which patients are receiving care in an emergent (unpredictable or unforeseen) situation. The findings are: A. Record review of the Emergency/Disaster Manual, undated, revealed the following: 1. No current copy of a dated Staff List 2. No current copy of a dated Patient List. B. On 10/21/2021 at 3:15 pm during an interview, Staff (S)#2 (Administrator) confirmed there was not a current staff list and a current patient list in the Emergency Preparedness manual.

Based on observation and interview, the facility failed to maintain a sanitary environment (an environment that is hygienic, clean, and conducive to infection prevention) as boxes of medical supplies were on the floor in the medical supply room. This deficient practice is likely to lead to contamination and potential infection control issues. The findings are: A. On 10/20/2021 at 9:45 am, during observation of the medical supply room, revealed the following: 1. Cardboard boxes with medical supplies stored on the floor (should store cardboard boxes off the ground due to their potential to grow and perpetuate bacteria, mold, or insects.) B. On 10/20/2021 at 9:50 am during an interview, Staff (S)#1 (Clinical Manager) confirmed the boxes on the floor and understood that there shouldn't be any boxes on the floor. Based on record review and interview the facility failed to maintain an infection control program by failing to provide education or screening of Tuberculosis (TB) (a serious infection, usually of the lungs caused by the bacteria Mycobacterium Tuberculosis, that is spread when you breathe in the air exhaled by a person infected with (TB)) to 1 (S3) out of 14 staff. This deficient practice could result in the spread of communicable organisms (diseases) to patients and their family members. The findings are: A. Record review of (S3) (Bereavement Coordinator) staff record revealed no record of yearly tuberculosis screening or tuberculosis education. 1. On 10/20/2021, record review of S3 (Bereavement Coordinator) staff file revealed no record of annual tuberculosis screening or tuberculosis education since date of hire on 02/15/2015. B. On 10/20/2021 at 1:00 pm interview with S2 (Administrator) confirmed the absence of Tuberculosis screening or education documentation in S3's (Bereavement Coordinator) file.

Based on record review and interview, the agency failed to ensure 6 (S4, S5, S6, S7, S8, S9) of 6 S(staff) staff/hospice aides had 12 hours of in-service training during the past 12 months. This failed practice places all patients currently receiving hospice aide services at risk for adverse outcomes due to potentially unsafe care by the hospice aide. The findings are: A. Record review of mandatory in-service training schedule for the year of 2021 revealed in-service training was scheduled for each month. B. Record review of S4, S5, S6, S7, S8 and S9 personnel charts revealed, all 6 employees had less than 12 hours of in-service training for 2021. C. On 10/21/2021 at 3:55 pm during interview with S1 (Clinical Manager) confirmed training documentation was not complete for the months of May, June, July, August, and September, indicating in-service training has not been completed.

Based on observation and interview the facility failed to ensure that items utilized for direct patient care are furnished appropriately by not using items passed expiration dates and not identified as being under an extended use authorization by the United States Food and Drug Administration. This failed practice is likely to lead to insufficient treatment and delayed progression to goals. The findings are: A. On 10/20/2021 at 9:30 am, observation of the medical supply room revealed the following expired (exp) products used in direct patient care: 1. Eight (8) Medline (product name) bottles of sterile water (for moistening dressings to remove from a wound): (4) exp on 07-15-2021 and (4) 08-20-2021 2. A bag of (100) Greiner bio-one (product name) yellow cap Vacuette urine collection tubes (clear glass tube used to collect urine): exp on 07-28-2021 3. Seven (7) boxes of Nestle Health Science Nutren 1.0 (product name) flavored drinks (a drink designed for patients with normal protein and calorie requirements): (4) exp on 03-09-2021, (2) 04-29-2021, and (1) 09-15-2021. B. On 10/20/2021 at 9:45 am during an interview, Staff (S)#1 (Clinical Manager) acknowledged the expired products in the supply room. S#1 reported there is not a set log to ensure that all product(s) is up to date. S#1 stated, "I check the supply room once a week or every other week to make sure there's nothing expired being used."