Every finding on record at Favoured Hospice LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: The effectiveness of drug therapy; Drug side effects; Actual or potential drug interactions; Duplicate drug therapy; Drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed the agency did not ensure that the medication profile included the patient’s current medications or updated new medications were added or changes were made to existing medications. CLINICAL RECORD 4: The patient’s election of the hospice benefit was 10/02/2025 with a primary diagnosis of Alzheimer's Disease. The nursing assessment dated 02/23/2026 documented that that the patient had hip discomfort and the patient was given Acetaminophen 1000mg for discomfort. The medication profile was not updated with this medication as of the record review on 02/26/2026. CLINICAL RECORD 9: The patient’s election of the hospice benefit was 11/18/2025 with a primary diagnosis of Atrial Fibrillation The nursing assessment dated 01/20/2026 documented that Voltaren ointment was being applied for pain control, however, the Voltaren was not on the medication profile as of the record review 02/25/2026. During interview with the director of nursing who stated that the medication profile had not been updated.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, it was revealed that the agency did not ensure that all interventions for problems identified in the initial and updated comprehensive assessments were included in the plan of care. CLINICAL RECORD 1: The patient’s election of benefits (EOB) was 05/23/2024 with a primary diagnosis of Lewy Body Dementia. The updated nursing assessment dated 02/06/2026 documented a pressure area on the coccyx. The last IDG (interdisciplinary group) dated 02/16/2026 did not include any documented evidence of interventions for the skin integrity or wound care. CLINICAL RECORD 8 : The patient’s election of benefits (EOB) was 12/23/2025 with a primary diagnosis of Alzheimer's Disease. The updated nursing comprehensive visit dated 01/06/2026 stated that the patient had a fall with some scrapes. There was no documented evidence of interventions for falls or safety on the updated plan of care dated 01/09/2026 or any of the plans updated every two weeks, as of review 02/26/2026. The initial plan of care dated 12/23/2025 included an intervention for the foley catheter to instruct in irrigation procedure but no specifics for what solutions to use for irrigation or amount or frequency that it could be irrigated. The plans of care updated every two weeks after the initial plan of care did not include any specifics for the foley irrigations. The nurse documented on the visit dated 01/27/2026 changing a dressing on a skin tear on the left elbow, cleaning it with normal saline, applying bacitracin and a Mepilex dressing. There was no documented evidence of an update to the plan of care or additional physician orders for the wound care provided as of the clinical record review 02/25/2026 During interview with the Director of Nursing on 02/27/2026 stated that the plans of care have been corrected and they have a new process in place.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following: Drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, it was revealed that the agency did not ensure that all medications were updated from the initial and updated comprehensive assessments were included in the plan of care. CLINICAL RECORD 4: The patient’s election of benefits (EOB) was 10/03/2025 with a primary diagnosis of Alzheimer's Disease. The updated nursing comprehensive assessment dated 02/23/2026 documented that that the patient had hip discomfort and was given was taking Acetaminophen 1000mg for discomfort. The plan of care was not updated for this medication as of review 02/26/2026. CLINICAL RECORD 9: The patient’s election of benefits (EOB) was 11/18/2025 with a primary diagnosis of Atrial Fibrillation. The updated nursing comprehensive assessment dated 01/20/2026 documented that Voltaren ointment was being applied for pain control, but this was not on any of the updated plans of care or the medication profile as of review 02/25/2026. During interview on 02/27/2026 with the clinical manager who reviewed the record, the clinical manager stated that the orders and were obtained but were not documented on the plan of care.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 9 of 13 (69%) clinical records reviewed, in which hospice aide services were provided, it was revealed that the agency did not ensure that the registered nurse prepared a hospice aide plan of care that contained clear and specific instructions for the patient's required care. CLINICAL RECORD 1/HOME VISIT 1: The hospice election of benefit was 05/23/2024 with a primary diagnosis of Lewy Body Dementia. The initial aide plan of care dated 05/23/2024 with a frequency that continued 2 times a week. The aide care plan was reviewed each benefit period with no changes. The last update was documented 02/06/2026. The initial comprehensive assessment 05/23/2024 documented that the patient was transferred per Hoyer lift. During the home visit with the hospice aide (Personnel Record 7) on 02/25/2026 a sign was posted that read the patient was to have Heel Float Boots on at all times. The aide stated that she always puts the boots on after the bath. The hospice aide was observed using the Hoyer lift and putting on the heel boots after the patient’s bath. The Hoyer Lift transfer and the heel float boots were not on the any of the hospice aide’s plan of care. CLINICAL RECORD 2: The hospice election of benefit was 05/06/2024 with a primary congestive heart failure. The patient resided in a memory care. The initial aide plan was dated 05/06/2024 and updated each benefit period with a visit frequency of 2 times a week. The assigned tasks were companionship, meal assist, perineal care, shower/bed bath, skin care every visit. The aide plan of care was not specific related to the type of bath to be given. CLINICAL RECORD 6: The hospice election of benefit was 10/13/2025 with a primary diagnosis of vascular dementia. The initial aide plan was dated 10/13/2025 and was updated every benefit period with an ordered frequency of 2 times a week. The aide assigned tasks were shower/bed bath, companionship, hair care, oral care, perineal care, each visit. The aide plan of care was not specific related to the type of bath to be given. CLINICAL RECORD 8: The hospice election of benefit was 12/23/2025 with a primary diagnosis of Alzheimer's Disease. The initial aide plan was dated 12/23/2025 and was updated with no changes every benefit period. The initial nursing assessment documented that the patient had a Foley catheter. Assigned tasks on the aide plan of care were companionship, oral care, perineal care, shower/bed bath every visit. The aide plan of care was not specific related to the type of bath to be given and did not include foley care. CLINICAL RECORD 9: The hospice election of benefit was 11/18/2025 with a primary diagnosis of Atrial Fibrillation. The initial aide plan was dated 11/18/2025 and was updated every benefit period with an ordered frequency of 2 times a week. The tasks assigned were collaborate with primary physician, reposition patient and that there was a left lower leg dressing. The patient had a Foley catheter placed 01/20/2026 and it was documented as of 12/16/2025 that the patient was to have compression stockings however, these task were not on the aide plan as of clinical record review 02/25/2026. CLINICAL RECORD 10: The hospice election of benefit was 06/05/2025 with a primary diagnosis of end stage myelodysplastic syndrome. The initial aide plan dated 06/05/2025 and was updated every benefit period with no changes and with an ordered frequency of 2 times a week. The initial nursing assessment documented that the patient had a foley catheter. Assigned tasks included oral care, perineal care, companionship and shower/bed bath minimally weekly. The aide plan of care was not specific related to the type of bath to be given and did not include foley care as of clinical record review 02/26/2026. CLINICAL RECORD 11: The hospice election of benefit was 10/20/2025 with a primary diagnosis of Alzheimer's Disease. The initial aide plan dated 10/20/2025 with an ordered frequency of 2 times a week. Assigned tasks were companionship, oral care, skin care and shower/bed bath every visit. The aide plan of care was not specific related to the type of bath to be given. CLINICAL RECORD 13: The hospice election of benefit was 05/12/2025 with a primary diagnosis of coronary artery disease. The initial aide plan was 05/12/2025 and updated 12/15/2025 with assigned task of companionship, meal assist, perineal care, skin care, shower/bed bath minimally weekly. The aide plan of care was not specific related to the type of bath to be given. Additionally on the initial nursing assessment, the patient transfer method was per Hoyer Lift but this was not documented on the aide plan of care. CLINICAL RECORD 14: The hospice election of benefit was 04/06/2025 with a primary diagnosis of Alzheimer's Disease. The initial aide plan was 04/06/2025 and updated each benefit period but had no assigned tasks for the following benefit periods 04/06/2025 - 07/04/2025, 07/05/2025 - 10/02/2025, 10/03/2025 - 12/01/2025. The patient died 12/16/2025. The hospice aide visited the ordered 2 times a week. During interview with the director of nursing and the administrator on 02/26/2026 stated that they had identified this earlier this year and started education and a process improvement plan to assure detailed plans.

It is required that all entries must be legible, clear, complete, and appropriately authenticated and dated in accordance with hospice policy and currently accepted standards of practice. This standard was not met as evidenced by clinical record review and interview. In 10 of 13 (77%) clinical records reviewed, in which a hospice aide provided care, the agency did not ensure that the hospice aide’s documentation included all services provided. CLINICAL RECORD 2: The hospice election of benefit was 05/06/2024 with a primary congestive heart failure. The patient resided in a memory care. The plan of care included an order for the hospice aide 2 times a week. The assigned tasks were companionship, oral care, meal assistance, perineal care, shower/bed bath, skin care every visit. The aide documented 01/29/2025 , 02/03/2025, 02/12/2025 patient showered and all personal care provided with no specific details of what the personal care. On 02/19/2026 the aide documented fed patient, showered and personal care provided with no specific details of what the personal care was. CLINICAL RECORD 5: The election of the hospice benefit was 11/05/2025 with an aide frequency order of 2 times a week. The assigned tasks were shower, perineal care, oral care and companionship to be completed each visit. The aide visits documented on 02/06/2026, 02/09/2026, 02/13/2026 documented companionship but 'no response' to all other assigned tasks with no explanation. CLINICAL RECORD 6: The election of the hospice benefit was 10/13/2025 with an aide frequency order of 2 times a week. The assigned task were shower/bed bath, companionship, hair care, oral care perineal care each visit. The visits documented 02/10/2026 documented that a bed bath was completed but no other care documented with 'no response to the assigned tasks. The visits 02/12/2026 documented 'personal care completed 'but did not document which of the tasks were completed. The visit documented 02/17/2026 documented companionship but all other tasks documented 'no response, with no reason documented. CLINICAL RECORD 7: The election of the hospice benefit was 08/06/2025 with an aide frequency order of 2 times a week. The assigned tasks were companionship, oral care, perineal care, shower/bed bath every visit. The aide visit documented 01/27/2026 documented companionship, no other care or reason for it not provided. On 02/05/2026 and 02/12/2026 the aide documented companionship, no other care or reason for it not provided. On 02/17/2026 the aide documented shower and other personal care (no detail of what this was) and no reason for the other care not provided. CLINICAL RECORD 8: The election of the hospice benefit was 12/23/2025 with an aide frequency order of 2 times a week. The assigned tasks were companionship, oral care, perineal care, shower/bed bath every visit. The aide documented on 02/04/2026 full care with bed bath but was not specific to what "full care”' meant. On 02/11/2026, the aide documented a bed bath given but all other care was documented as 'no response'. On 02/16/2026, the aide documented a shower but all other care was documented 'no response'. The visit 02/18/2026 the aide documented a bed bath and person care but was not specific for what personal care was completed. CLINICAL RECORD 9: The election of the hospice benefit was 11/18/2025 with an aide ordered frequency of 2 times a week. The assigned tasks were collaborate with physician, turn and reposition patient, and that the patient had a left lower leg wound. The aide documented 02/04/2026 that a bed bath was given and personal care, 02/09/2026 shower and all personal care, 02/06/2026 all personal care and 02/11/2026 all personal care provided and companionship. These tasks were not assigned. CLINICAL RECORD 10: The election of the hospice benefit was 06/05/2025 with an aide ordered 3 times a week. The assigned tasks were companionship, meal assist, oral care, perineal care, shower/bed bath minimally weekly. On the aide visit dated 11/19/2025, the aide documented a partial bed bath, companionship and 'no response' to the other assigned tasks. On 11/10/2025 documented barrier cream applied to bottom and companionship with no other care documented or reason why. On 01/16/2026 a full bed bath, emptied catheter but these were not assigned tasks. 01/29/2026 and 02/17/2026 and 02/19/2026 bed bath and personal care., but not specific to what the personal care included. CLINICAL RECORD 11: The election of the hospice benefit was 10/20/2025 with an aide ordered frequency of 2 times a week. The assigned tasks were shower/bed bath, perineal care, and companionship each visit. The aide documented on 10/17/2025 bed bath and all personal care, the visit 10/20/2025 documented all care provided but notes were nonspecific for what specific care was provided. CLINICAL RECORD 13: The election of the hospice benefit was 05/12/2025 with an aide ordered frequency of 2 times a week. The assigned tasks were companionship, meal assist, perineal care, skin care, shower/bed bath minimally weekly. The aide documented 10/17/2025, 10/29/2025, 11/12/2025 that companionship was provided but no other care or reason why not provided. On 11/19/2025, the aide documented companionship and refused care but no nurse notification and 11/21/2025 documented all personal care provided (nonspecific to which it was) and up in wheelchair. This was not a task that was assigned. CLINICAL RECORD 14: The election of the hospice benefit was 04/06/2025 with an aide ordered frequency of 2 times a week. The aide care plan had no assigned tasks from 04/06/2025 through 12/16/2025. The aide documented 11/03/2025 all personal care done, Got dressed, Used EZ stand to transfer. The aide note was nonspecific to what care was provided. On 11/12/2025 and 11/26/2025 , the aide documented shower and personal care , transfer to wheelchair; 12/11/2025 bed bath and dressed; 12/30/2025 shower and other cares; Transfer to wheelchair. During interview with the Director of Nursing and administrator stated that they had identified this earlier this year and started some paper documentation as the software does not present the plan clearly to the aides and they self-recognized this problem and have a process improvement in place.