Every finding on record at Gamma Hospice Care Inc

Upon patient record review, 2 of 5 (Patients #3 and 5) did not contain a current/comprehensive Medication Profile: Patient #3: The Medication Profile listed, "Lidocaine Patch 5%, on 12 hours and off 12 hours, without a location on the body for which to locate such patch. Patient #5: The Medication Profile listed, "Oxygen 0.995 mg/ml. This is not a correct Oxygen dosage.

Upon patient record review, the agency did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient as there was no new admissions after compliance date therefore unable to abate.

Upon patient record review, 2 of 5 (Patient #1,#4) did not contain evidence that the IDG had ensured that care and services were provided in accordance with the Plan of Care: Patient #1: The POC ordered SN visits 1x per week. There was no documented SN visit for the week of June 1-7, 2025. Patient #4: The IDG POC dated 06/03/25 listed, "SW visits one per week" however, there was no evidence of visits the week of 06/01 or 06/09/25. The RN Case Manager reported that this was an incorrect entry. It should have been entered as, "SW visits one per month."

Upon patient record review, 1 of 5 (Patient #3) did not contain evidence that the IDG had documented the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement: Patient #3: The RN documents within the 05/30/25 home visit, "Notable respiratory distress, SOB at rest, wheezing, dry cough, and reliance on accessory muscles to breath. Auscultation reflects decreased breath sounds, and scattered rhonchi; indicating an active infection and worsening of condition." There was no documented evidence that the RN had reported these findings to the Hospice Medical Director. Neither did the next subsequent 06/03/25 IDG Meeting notes reflect the patient's updated condition/status to the rest of the Interdisciplinary Team.

Upon patient record review, 1 of 5 (Patients #2) did not contain evidence that all entries were legible, clear, and complete: Patient #2: The IDG POC dated 06/03/25 included: 1. SN - Visits 1x per week; and 2) Other - Visits 2x per month. The RN Case Manager states that the "SN" visit frequency entry is intended to reflect the frequency of LVN visits, and the "Other" frequency entry is intended to reflect the frequency of an RN conducting LVN supervisory visits every 2 weeks (per their practice). This is unclear documentation, as the neither of these entries specify what clinician is to be making these entered visit frequencies.

Upon patient record review 4 of 14 (Patient #3,4,7,9) 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 3: Patient admitted 1/5/25 and referred to SC for initial spiritual assessment. Initial spiritual assessment documented in the medical record on 1/16/25. Patient 4: Patient admitted 10/29/24 and referred to SC for initial spiritual assessment. Initial spiritual assessment documented in the medical record on 1/27/25. Patient 7: Patient admitted 7/3/24 and referred to SC for initial spiritual assessment. Initial spiritual assessment documented in the medical record 1/20/25. Patient 9: Patient admitted 8/12/24 and referred to SC for initial spiritual assessment. Initial spiritual assessment documented in the medical record 2/10/25.

Upon patient record review, 7 of 14 (Patient #1,2,3,4,5,6,8) 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 1,2,3,8: Patient has oxygen listed as a treatment in the plan of care. There is no evidence of this medication on the medication list. COS Patient 4: Patient with medication lidocaine 5% ointment on the medication list. Instructions: apply to affected area, 12 hours on and 12 hours off, for pain management. There is no evidence of application site for this medication. COS Patient 5,6: Patient has oxygen listed as intervention in the plan of care. There is no evidence of this medication on the medication list. COS Patient 6: Medication diclofenac 1% topical ointment on medication list with instructions: apply to affected area daily, use as directed. There is no evidence of application site or indication for this medication on the medication list. Medication nitroglycerin 0.4mg on the medication list with instructions: one tablet sublingual as needed for angina. There is evidence of incomplete medication instructions for this medication on the medication list. Medication lidocaine patches on the medication list with instructions: one patch topical (see note) 12 hours on/12 hours off. There is no evidence of patch dosage, application site, application amount, indication. There is also no evidence of referred note for this medication on the medication list. Medication potassium chloride on the medication list with instructions: KCl 8, 1 tab by mouth daily for nausea, vomiting. There is no evidence of dose on the medication list. All COS

Upon patient record review, 1 of 14 (Patient #6) 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 6: There is no evidence of documented RN visit since 4/18/25.

Condition of participation: Interdisciplinary group, care planning, and coordination of services. The hospice must designate an interdisciplinary group or groups as specified in paragraph (a) of this section which, in consultation with the patient's attending physician, must prepare a written plan of care for each patient. The plan of care must specify the hospice care and services necessary to meet the patient and familyspecific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions.

Upon patient record review, 8 of 14 (Patient #1,2,3,4,5,6,8,10) 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 1,2,3,5,8,10: Respiratory care plan with intervention: instruct proper and safe use of oxygen at _ liters per minute via nasal cannula or mask. There is no evidence of oxygen dose in this intervention. All COS Patient 1: Seizure precautions identified as a need during initial comprehensive assessment, dated 3/11/25. There is no evidence of seizure plan of care with problems, goals, interventions in the medical record. COS Patient 2: Immobility and incontinence X2 both on plan of care with problems, goals, interventions due to identified needs during initial comprehensive assessment dated 7/22/24. There is no evidence of problems, goals, interventions on the plan of care for high risk for skin breakdown. COS Patient 4: Edema was identified during initial comprehensive assessment dated 10/29/24. There is no evidence of edema plan of care including problems, goals, interventions. COS Patient 6: Aspirin 81mg on plan of care with indication CVA prophylaxis, added on admission 4/1/25. There is no evidence of bleeding risk plan of care with problems, goals, interventions. COS Patient 8: Aspiration precautions identified as a need during initial comprehensive assessment, dated 5/3/24. There is no evidence of plan of care with problems, goals, interventions for this identified need.

Upon patient record review, 7 of 14 (Patient #1,2,3,4,5,6,8) 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 1,2,3,8: Patient has oxygen listed as a treatment in the plan of care. There is no evidence of this medication order on the plan of care. COS Patient 4: Patient with medication lidocaine 5% ointment on the plan of care. Instructions: apply to affected area, 12 hours on and 12 hours off, for pain management. There is no evidence of application site for this medication in the plan of care. COS Patient 5,6: Patient has oxygen listed as intervention in the plan of care. There is no evidence of this medication order on the plan of care. COS Patient 6: Medication diclofenac 1% topical ointment on plan of care with instructions: apply to affected area daily, use as directed. There is no evidence of application site or indication for this medication on the plan of care. Medication nitroglycerin 0.4mg on the plan of care with instructions: one tablet sublingual as needed for angina. There is evidence of incomplete medication instructions for this medication on the plan of care. Medication lidocaine patches on the plan of care with instructions: one patch topical (see note) 12 hours on/12 hours off. There is no evidence of patch dosage, application site, application amount, indication. There is also no evidence of referred note for this medication on the plan of care. Medication potassium chloride on the plan of care with instructions: KCl 8 1 tab by mouth daily for nausea, vomiting. There is no evidence of dose for this medication on the plan of care. All COS

Upon patient record review, 6 of 14 (Patient #2,4,5,6,7,10) 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 2,4,6: DME need identified with no evidence of DME in the plan of care: oxygen. COS Patient 5: DME need identified with no evidence of DME in the plan of care: oxygen. Oxygen supplies listed, concentrator/tanks not listed. COS Patient 7: DME need identified with no evidence of DME in the plan of care: wheelchair. COS Patient 10: DME need identified with no evidence of DME in the plan of care: walker, shower chair. COS

Upon patient record review, 2 of 14 (Patient #10,11) 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 10: 4/19/25 recertification visit documents oxygen use. There is no evidence of updated plan of care to include oxygen problems, goals, interventions. COS Patient 11: Patient was discharged due to being no longer terminally ill. There is no evidence of discharge planning in the patient's medical record.

Upon patient record review, 6 of 14 (Patient #1,2,3,4,5,7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: SC visit frequency order is evaluation only. Documented SC visits 3/13 and 4/11. Clarification order entered during survey for monthly SC visits. Patient 2: SC visit frequency order is once per certification period. Documented SC visits 10/25/24, 1/22, 2/21, 3/18/25. Clarification order entered during survey for monthly SC visits. Patient 3: SC visit frequency order is evaluation only. Documented SC visits 1/16, 3/13, 4/11/25. Clarification order entered during survey for monthly SC visits. Social worker visit frequency order is evaluation only. Documented social worker visits 1/9, 4/6/25. Patient 4: Patient admitted 10/29/24 in certification period 2. SC visit frequency order is once per certification period. Documented SC visits: 1/27, 2/27, 3/21/25. All visits occurred during certification 3, dating 1/27/25-3/27/25. Patient 5: SC visit frequency order is evaluation only. Documented SC visits 2/10, 3/10, 4/10/25. Clarification order entered during survey for monthly SC visits. Patient 7: SC visit frequency orders: one visit during certification periods dated 10/1/24-12/29/24 (2 of these orders); 12/30/24-2/27/25 and 4/29/25-6/27/25 (2 of these orders). Documented SC visits: 1/20/25, 2/20/25, 3/20/25. Social worker visit frequency orders: one visit during certification periods dated 7/3-9/30/24; 10/1/24-12/29/24 (3 of these orders); 12/30/24-2/27/25; X1 visit on 2/28/25; and 4/29/25-6/27/25; and one PRN. Documented social worker visits: 7/6, 10/2, 10/5, 12/31/24, 1/3, 4/30/25.

Upon patient record review, 1 of 14 (Patient #10) 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 10: Visit frequency order for aide beginning 7/24/24 is twice weekly. There is no evidence of aide care plan in the medical record.

Upon patient record review, 1 of 14 (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: In the visit summary for the death note, another patient’s name is used. Addendum was added during survey day 2, acknowledging and correcting error.