Every finding on record at Heritage Health & Hospice Care, LLC

Upon patient record review 2 of 19 (Patient #7,8) 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 7: The record indicates that the psychosocial assessment was not completed within 5 calendar days following the election of hospice. Patient was admitted on 11/08/2024. Psychosocial assessment completed on 01/06/2025, 59 days after election. Patient 8: The record indicates that neither the psychosocial nor the spiritual assessment were completed within 5 calendar days following the election of hospice. Patient was admitted on 04/26/2024. Psychosocial assessment completed on 05/07/2024, 11 days after election. Spiritual assessment/mini assessment was completed on 02/18/2025.

Upon patient record review, 2 of 19 (Patient #1,2) 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 nursing documentation indicated the patient was admitted on PRN oxygen and currently uses oxygen for PRN for shortness of breath. No evidence of oxygen listed on the current medication profile. Corrected on site. Patient 2: During observation of home visit and medication reconciliation, the active SNF medication profile contained Atorvastatin 20mg by mouth daily and is missing the comfort medications orders. No evidence that atorvastatin and oxygen is listed on the current hospice medication profile. Comfort medication was listed on the current hospice medication profile. Corrected on site.

Upon patient record review, 1 of 19 (Patient #3) 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 3: No evidence that an RN assessed the patient as the condition required but no less frequently than every 15 days. The record indicates that there were 16 days between RN assessments on 12/17/2024 and on 01/02/2025.

Upon patient record review, 1 of 19 (Patient #2) 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. Patient 2: The record indicates that the patient has multiple wounds. No evidence that the wound was measured on the week of 01/26/2025. The wound remains active in the wound chapter and the plan of care has active wound care orders. Gentiva policy is for wounds to be measured weekly.

Upon patient record review, 1 of 19 (Patient #1) 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: Patient has depression listed as a related diagnosis and currently takes Bupropion HCL 75mg daily for depression. There was no evidence of problems, goals, and interventions related to depression included in the plan of care. Corrected on site.

Upon patient record review, 1 of 19 (Patient #12) 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. Patient 12: The record indicated that the initial POC did not address SW or Chaplain frequencies. No order for evaluation by either discipline. The RN initial comprehensive assessment indicated that an evaluation was needed by both disciplines.

Upon patient record review, 1 of 19 (Patient #1) 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 nursing documentation indicated the patient currently uses oxygen for PRN for shortness of breath. No evidence that an order was received for oxygen. Corrected on site.

Upon patient record review, 2 of 19 (Patient #1,13) 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 nursing documentation indicated that the patient uses oxygen via NC PRN for shortness of breath. No evidence that an order was received to add the oxygen concentrator/supplies to the current POC supply list. Corrected on site. Patient 13: The current plan of care has wound care supplies listed on the current POC. No evidence that the patient has had a wound during time on service. Corrected on site.

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: The POC has chaplain visits ordered as monthly. No evidence that a visit occurred for the month of December 2024 or January 2025. No evidence that visit was missed at the request of the patient/CG or that an order was received to decrease visits for the week.

Upon patient record review 2 of 19 (Patient #4,7) 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 4: The record indicated that the aide plan of care has visit frequency ordered at 3 times a week. No evidence that 3 visits occurred for the weeks of 11/24/2024, 12/29/2024, 02/09/2025. No evidence that the visit was missed at the request of the patient/CG or that an order was received to decrease the visits for that week. Patient 7: The record indicated that the aide plan of care has visit frequency ordered 5 times a week. No evidence that 5 visits occurred for the weeks of 11/24/2024, 12/01/2024, 12/22/2024 and 12/29/2024. No evidence that the visits were missed at the request of the patient/CG or that an order was received to decrease the visits for that week.

Upon patient record review 2 of 19 (Patient #3,7) 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 3: The record indicated that patient has been receiving aide services since the time of admission. No evidence that a registered nurse made supervised visits every 14 days between 12/17/2024 & 01/07/2025 (16 days between supervised visits) and again between 01/07/2025 & 01/27/2025 - 20 days between supervised visits. Patient 7: The record indicated that patient has been receiving aide services since the time of admission. No evidence that a registered nurse made supervised visits every 14 days between 11/18/2024 & 12/16/2024 (28 days between supervised visits).

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. The documentation indicated that the volunteer percentage for the provider number 2024 was 4.45%.

Upon patient record review, 3 of 19 (Patient #1,2,3) 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 1: The record indicated that the aide entered a missed visit note on 11/20/2024 that was not completed. No evidence of what date the visit was missed and which RN was notified that the visit was missed. Patient 2: The record indicated that the aide entered a missed visit note on 12/23/2024, 12/25/24, and 12/27/24 that was not completed. No evidence of what date the visit was missed and which RN was notified that the visit was missed. Patient 3: The record indicated that the aide entered a missed visit note on 11/29/2024 that was not completed. No evidence of what date the visit was missed and which RN was notified that the visit was missed. Also the RN entered a missed visit note on 12/28/2024 that was not complete. No evidence of what date the visit was missed was listed in the note.

Upon patient record review, 1 of 19 (Patient #1) 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: The plan of care has nurse visits ordered as twice a week. No evidence that 2 visits occurred for the week of 11/24/2024. One visit documented on 11/25/2024. No evidence that visit was missed at the request of the patient/CG or that an order was received to decrease visits for the week.

Upon patient record review, 1 of 19 (Patient #2) 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 2: The record showed that an order written on 01/15/2025 for wound care orders did not include a frequency to change the dressing or detailed instructions for who is responsible for performing the dressing changes, the hospice nurse or the facility nurse. Corrected on site.

Based on record review and interview the hospice failed to routinely make nursing services available 24 hours a day, seven days a week for 1 of 3 patients (#1) reviewed, in that: The patient and the family suffered adverse effects for the SN not responding to the afterhours call. This failure could place clients at risk for further discomfort and family distress. Findings include: Record review of HHSC Consumer Rights and Services Complaint Investigation Worksheet #369260 notes in TULIP read in part: "Two days prior to [Patient #1] passing, [Patient #1] had been ill all night and I needed guidance from the nurse. She advised she would examine him the next morning. My concern was staffing due to another holiday weekend. The next day a nurse [LVN A] arrived that afternoon. She then placed a three-way call to the director [RN A] and [Physician A] for instructions. By 3:00 PM that same afternoon, [Patient #1] became extremely ill and agitated. I quickly contacted the same nurse [LVN A] and I placed [Patient #1] on a FACETIME call so she could see his debilitating condition. By this time, it was urgent for a nurse to attend to him as soon as possible. She stated that his condition was only due to Parkinson's. Her advice over the phone was to administer morphine. As [Patient #1] care taker I had not been trained on the use of morphine. By 3:00 AM that morning, in panic, I contacted the same nurse [LVN A] due to the fact that [Patient #1] was not breathing properly. She told me to contact the 24-hour nurse. When I did not receive a call back, I called EMS and they arrived immediately. However, it was too late, [Patient #1] had just passed away. When the 24-hour nurse finally arrived, she had no equipment and did not bother to confirm he was deceased." Review of the clinical record for Patient #1 showed a start of care date of 12/31/2021 and a terminal diagnosis of Parkinson's disease. Review of the POC for certification period 12/31/2021 to 3/30/2022 showed orders for the hospice nurse to instruct caregiver(s) on levels of consciousness and to report changes to hospice nurse. SN to provide instructions for performing gastrostomy feedings to include care of equipment and preparation of feedings. Hospice nurse to instruct on respiratory status. The POC included the SN frequency of twice a week for week 1, once a week beginning week 2, 4 PRN for symptom management. The POC included the medication of Morphine Concentrate 100 MG /ML oral solution 5 mg hourly/PRN for dyspnea. Review of the SN PRN visit note dated 01/15/2022 [per family, this visit was made around noon time] signed by LVN A read in part: "SN received PRN on-call visit request, from pt's wife. Patient's wife worried about continuous episodes of diarrhea by husband. Pt had gone 3 days without a BM & received a suppository on 1/13/22. Pt began to have excessive loose watery stools on 1/14. The wife noted she had been up all night changing pts brief every 30 minutes ....SN communicated with RN A with update and recommended plan of care for visit. Physician A also updated ....SN noted to wife to contact us 24/7 with questions or concerns. Wife voiced understanding." Review of RN B visit note dated 01/16/2022 showed "Family called 911 - EMS responded and pronounced death on arrival by 0347 on 01/16/2022." During interview on 08/30/22 at 5:17 p.m. with Family Member stated that on 01/15/22 around noon LVN A made a visit to Patient #1 due to diarrhea. LVN A made a 3 way call to RN A and Physician A and orders were to stopped feedings and only give Pedialyte and water. Same day around 7 p.m, Patient #1 was disrupt "something was wrong" and she made a telephone call to LVN A and also made a FaceTime call to LVN A requesting a visit to Patient #1. Family Member stated that she made the FaceTime call to show the nurse how sick Patient #1 was. LVN A stated that it was his Parkinson's disease and instructed to give Morphine. Family Member stated that she placed 2 drops of Morphine under the patient's tongue. Family Member stated that she was not instructed on the use of Morphine and she was afraid to give the Morphine. Family Member stated that later around 1:00 a.m. or 1:30 a.m. [on 01/16/22] Patient #1 was wet, she changed the diaper and the bed. Later she heard a bed shake, he was having breathing problems and she called LVN A again. LVN A said to call the 24-hour nurse, she called the 24-hour nurse and there was no response. Since the 24-hour nurse did not responded then she called EMS. When EMS arrived, it was too late he had passed away. The hospice 24-hour nurse came after EMS had arrived. During interview on 08/31/22 at 10:25 a.m. with LVN A revealed that she made a PRN visit to Patient #1. LVN A stated that Patient #1 was having diarrhea, they changed him 2 or 3 times. LVN A stated that the spouse was very anxious and she gave her personal phone number to the spouse. LVN A stated that the spouse kept calling her. LVN A was asked why the patient's family call her on FaceTime and LVN A stated that the wife and daughter called her to report he [Patient #1] was doing much better. "She [spouse] was very appreciative for the help." They FaceTime me to show how well he was doing, he was sitting on the side of the bed." LVN A stated that the wife kept asking questions about end of life. LVN A was asked why family members call her later on 01/16/22 and she instructed her to call the 24-hour nurse. LVN A stated that if she instructed her to call the 24-hour nurse it was because she was unable to assist. LVN A was ask if she documented the phone calls she received from the patient's family and her interventions and LVN A stated, "I don't remember." Review of the spouse telephone records for 01/15/22 showed the patient's spouse called LVN A at 11:57 a.m. and 7:19 p.m. and on 01/16/22 at 3:23 a.m. Also review of Face Time phone record showed a call to LVN A on 01/15/22 at 7:21 p.m. for a duration of 9 minutes. Review of the hospice on-call record dated 01/16/22 at 3:30 a.m. showed a message "Patient expired." The administrator stated that this was the only on-call record for Patient #1 for 01/15/22 to 01/16/22. During interview on 08/31/22 at 9:28 a.m. with RN A, she was informed that on 01/15/22 and 01/16/22 Patient #1's family had called LVN A and the on-call nurse to report the patient's change in condition and had requested a nurse visit. RN A was asked if she was aware of this and if the hospice had documentation of this. RN A stated that she was not aware of the incident and not aware of any on-call issues. At the time of the incident RN A was the executive director. During interview on 8/31/22 at 2:50 p.m. with the Administrator she was asked if the hospice had documentation that LVN A received phone calls from Patient #1's family on 01/15/22 and 01/16/22 and documentation of the interventions she made to these calls. The administrator stated that she was not aware of the incident and she was going to look for LVN A documentation. Later the Administrator informed surveyor that they did not find additional documentation. Review of the hospice policy and procedure titled "Hospice Nurse Care" with a revised date of 6/27/2022 reads in part: "The hospice nurse will: Provide patient and family/caregiver education regarding the disease process, self-care techniques, end-of-life care, and processes for addressing ethical issues. Provide emotional support to the patient and family. Assess the ability of the caregiver to meet the patient's immediate needs upon admission and throughout care. A hospice nurse will be available on a 24-hour basis to meet the physical, psychosocial, spiritual, and practical needs of patients and families/caregivers admitted to the hospice program. Licensed practical/vocational nurses will supplement the nursing care needs of the patient as provided by the registered nurse; this may include: Assist the RN in implementing the plan of care and will report the condition of patient and family/caregiver to the RN and interdisciplinary group on a regular basis, as well as suggested changes to the plan of care. Preparing clinical and progress notes documenting outcome of interventions.

Based on record review and interview the hospice nurse failed to enforce the hospice policy for disposal of controlled substances for 1 of 3 patients (#1) reviewed, in that: The RN failed to dispose the patient's Morphine after the patient's death or failed to teach the family of the proper disposal of controlled substances. This failure could place patients or family members at risk for accidental or intentional misuse of controlled substances. Findings include: Record review of HHSC Consumer Rights and Services Complaint Investigation Worksheet #369260 notes in TULIP read in part: "No instructions were given as to how to dispose of controlled substances." Review of the clinical record for Patient #1 showed a start of care date of 12/31/2021 and a terminal diagnosis of Parkinson's disease. Review of the POC for certification period 12/31/2021 to 3/30/2022 showed orders for the hospice nurse to instruct caregiver(s) on levels of consciousness and to report changes to hospice nurse. The POC included the SN frequency of twice a week for week 1, once a week beginning week 2, 4 PRN for symptom management. The POC included the medication of Morphine Concentrate 100 MG /ML oral solution 5 mg hourly/PRN for dyspnea. Review of RN B visit note dated 01/16/2022 showed "Family called 911 - EMS responded and pronounced death on arrival by 0347 on 01/16/2022." Further review of the visit note under the medications section, RN B documented the following: Indicate if agency staff disposed of Medications. "No." Indicate reason Meds were not disposed by agency. "family/caregiver wanted to dispose of meds." Indicate if the staff educated family/caregiver on drug disposal. "yes." Indicate if family/caregiver verbalized understanding of drug disposal policy. "yes." Indicate if family/caregiver disposed of medications. "yes." Indicate name of family/caregiver who disposed of medication. "Daughter." Indicate medications disposed. "Morphine Sulfate Elixer (Roxanol)." Indicate Morphine Sulfate Elixer Strength, Route, Amounted Wasted. "20 mg/ml." Method of disposal. "coffee grounds." Indicate who witnessed disposal of medications by family/caregiver. "agency nursing staff [RN B]." During interview on 08/30/22 at 5:17 p.m. with Family Member stated that when Patient #1 passed away, the 24-hour nurse (RN B) came after EMS arrived and Patient #1 had already passed away. Family Member stated that RN B stayed in the kitchen all the time, did not approached the patient, and RN B did not request the medications. Family Member stated that Patient #1's Morphine still in the home. Family member provided the following pictures on 08/31/22: Review of picture #1 showed a medication bottle for Morphine Sulfate for Patient #1. Review of Picture #2 showed blue liquid medication draw to the syringe from the Morphine bottle. During interview on 08/31/22 at 10:10 a.m. with RN B, she stated that from what she recalls the patient family called, she went out within an hour for a death visit. RN B stated that the family had called EMS and EMS pronounce death. RN B was asked if she disposed Patient #1's substance-controlled medication [Morphine] and RN B stated "yes, with the Sheriff." Then RN B stated "I don't recall, it's been 8 months. It's whatever was documented in the visit note." During interview on 8/31/22 at 2:50 p.m. with the Administrator she was asked for the hospice procedure for disposing controlled substance medications in the patient's home. The administrator stated that hospice staff is not required to dispose of the medication, they can assist the family, instruct how to dispose the medication and staff is not allowed to take the medications. Review of the hospice policy and procedure titled "Home use and disposal of controlled substances" with a revised date of 6/24/2022 reads in part: "Disposal following a patient's death or drug expiration: To the extent consistent with applicable state law as summarized in Addendum A to this policy, at the time of death or when a controlled Substance is no longer needed because the drug has expired, a Registered Nurse and/or LVPN/LVN employed by the hospice, who is trained to dispose of controlled substances will dispose of the controlled substance. The hospice Registered Nurse and/or LVPN/LVN will be witnessed by a member of the patient's family who is 18 years of age or older or a second hospice Registered Nurse and/or LVPN/LVN, as allowed by state law. Prior to disposing of a patient's medication, the hospice Registered Nurse and/or LVPN/LVN will check the medication label to confirm that the medication belongs(ed) to the patient. After disposing of the controlled substances, the hospice Registered Nurse and/or LVPN/LVN who performed the disposal will document on the paper Medication Disposal form and in the patient's electronic medical record (EMR), the name, type, dosage, route of administration, and quantity of the controlled substance that disposed as well as the time, date, and manner in which the disposal occurred. The hospice Registered Nurse and/or LVPN/LVN will obtain the witness signature on the paper form. The Medication Disposal form will be turned in to the office to be scanned in the EMR."

Upon patient record review, 1 of 16 (Patient #6) 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- Patient was admitted on 9/15/21 and the spiritual assessment was not completed until 10/28/21.

Upon patient record review, 2 of 16 (Patient #14, #15) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #14 -Patient was admitted on 9/25/19 and there is no evidence a spiritual assessment was completed. Patient #15- Patient was admitted on 1/21/22 and there is no evidence a spiritual assessment was completed.

Upon patient record review, 6 of 16 (Patient #1, #4, #6, #7, #8, #13) 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. Patient #1- On 2/17/22 the medication profile includes Morphine 100/mg 5ml hourly PRN as directed. Give .75 ml po sl for pain/SOB on pain scale every 1 hour as needed. The pain scale levels for administration were not included in the profile. Patient #4 -The medication profile includes duplicative/unclear dosing for Acetaminophen. 09/15/21 Children's Acetaminophen 160mg/5ml 10 ml q8h prn pain or discomfort. The profile also includes 09/18/22 Acetaminophen 160 mg/5ml 10-20 ml q6h prn pain . Patient #6 - The medication profile includes duplicative/unclear dosing for Lorazepam. 9/15/21 Lorazepam .5mg 1 tablet every 2h as needed. The profile also includes Lorazepam 2mg tablet-take1/2 to 1 tablet (1mg to 2mg) q4h as needed. Patient #7- The medication profile includes duplicative/unclear dosing for Oxygen. 1/4/22 Oxygen 2-3 liter daily PRN for sob. The profile also includes Oxygen humidified 2-4 liters PRN for sob. On 1/4/22 the medication profile includes Morphine 100/mg 5ml with a frequency of intermittent. The frequency is unclear. Patient #8- The medication profile includes Acetaminophen 650 mg rectal suppository q6h for constipation. Constipation was written in error. Patient #13- The medication profile includes duplicative unclear dosing for Acetaminophen and does not indicate maximum mg daily not to be exceeded. There is no differentiation on when to use rectal versus po. The medication profile includes Acetaminophen 650 mg rectal suppository q4h PRN for fever and mild pain. The profile also includes Acetaminophen 650 ER 650 mg tablet q12h for pain. The profile also includes Tylenol 325 mg tablet q6h PRN for fever and mild pain.

Upon patient record review, 4 of 16 (Patient #5, #7, #13, #14) 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. Patient #5- was admitted on 1/5/22 and the bereavement risk assessment was not performed until 2/9/22. Patient #7- was admitted on 1/4/22 and a bereavement risk assessment is not on record. Patient #13- was admitted on 1/6/22 and a bereavement risk assessment was not performed until 2/23/22. Patient #14- was admitted on 9/25/19 and a bereavement risk assessment is not on record.

Upon patient record review, 2 of 16 (Patient #6, #13) 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). Patient #6- On 10/6/21 the triage RN documented receiving a phone call from patient regarding med refills and stated he was out of medication. There is no further documentation regarding the patients concern and the next visit did not occur until 10/13/21. Patient #13- On 1/9/22 the triage RN documented receiving a call from ALF staff member wanting clarification on a medication and route. ALF staff asked that a new order be written the following day 1/10/22 and faxed to facility with follow up from RN. There is no further documentation regarding the request, no evidence of a new order on 1/10/22 and the next visit did not occur until 1/12/22.

Upon patient record review, 5 of 16 (Patient #1, #4, #6, #7, #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 specific orders for all medications. Patient #1- On 2/17/22 the POC was updated with orders for Morphine 100/mg 5ml hourly PRN as directed. Give .75 ml po sl for pain/SOB on pain scale every 1 hour as needed. The pain scale levels for administration were not included in the plan of care. Patient #4 -The 12/29/21 POC includes duplicative/unclear dosing for Acetaminophen. 09/15/22 Children's Acetaminophen 160mg/5ml 10 ml q8h prn pain or discomfort. The POC also includes 09/18/22 Acetaminophen 160 mg/5ml 10-20 ml q6h prn pain . Patient #6 - The 9/15/21 POC includes duplicative/unclear dosing for Lorazepam. 9/15/21 Lorazepam .5mg 1 tablet every 2h as needed. The POC also includes Lorazepam 2mg tablet-take1/2 to 1 tablet (1mg to 2mg) q4h as needed. Patient #7 -The 1/4/22 POC includes Morphine 100/mg 5ml with a frequency of intermittent. The frequency is unclear. Patient #8 - The 1/8/22 POC includes Acetaminophen 650 mg rectal suppository every 6h for constipation. Constipation was written in error.

Upon patient record review, 1 of 11 applicable (Patient #14) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the plan of care. Patient # 14- The aide care plan indicated to bathe and shampoo 3x weekly and shaving 2x weekly. The record indicated that the task of bathing, shampoo and shaving was provided at every visit (5xwk) by the aide week of 2/19/21 and 3/1/21.

Upon patient record review, 2 of 16 (Patient #8, #13) did not have evidence that each patient record contains a signed election statement in accordance with 418.24. Patient #8- On 1/8/22 the patient elected to receive the notice of non coverage addendum on the consent paperwork and the record indicated the family signed that they received the notice of non coverage on 2/4/22. Patient #13- On 1/6/22 the patient elected to receive the notice of non coverage addendum on the consent paperwork. There is no evidence that the addendum was delivered to the patient.

Upon patient record review, 1 of 16 (Patient #1) did not have evidence that all entries are clear and complete. Patient #1- On 1/4/22 LVN documented "The patient had been smoking and put cigarette when SN entered". Documentation is not clear. On 1/6/22 the nurse documented administering morphine .25 oral solution sublingual. Dosage is incomplete for the actual amount administered.