Every finding on record at Heritage Hospice, LLC

Upon patient record review, 4 of 14 (Patient #1,#3,#5,#9) 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 and 3:The SN documented that the patient required oxygen at 2 LPM as needed for shortness of breath. There is no evidence that the medication profile includes an entry for oxygen. Patient 5:The medication profile included duplicate orders for oxygen written on 11/25/24 and 11/26/24 with no end date noted. Patient 9:The SN documented that the patient required oxygen at 3 LPM as needed for shortness of breath. There is no evidence that the medication profile includes an entry for oxygen.

Upon patient record review, 2 of 14 (Patient #2,#3) 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 2:The medical record includes a notation under safety measures that the patient has history of consuming non edible items and to make sure hazardous substances are not accessible. There is no evidence that the plan of care includes interventions and goals under safety problem for this risk. Patient 3:The medical record includes an order for Xarelto for anticoagulation therapy. There is no evidence that the plan of care includes problems, goals, and interventions for the risk of bleeding.

Upon patient record review, 3 of 14 (Patient #1,#3,#9) 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, 3, and 9:The medical record includes documentation that the patient requires oxygen for shortness of breath. There is no evidence that the plan of care includes an order for oxygen.

Upon patient record review, 1 of 14 (Patient #9) 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 9:The medical record includes SN documentation that the patient has a history of falls and requires oxygen at 3LPM via nasal cannula. There is no evidence that the plan of care includes problems, goals and interventions for management of the risk for falls and the use and safety of oxygen.

Upon patient record review, 1 of 14 (Patient #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 5:The plan of care includes an order to discontinue the foley catheter for a 4 hour trial. There is no documentation to support the removal of the catheter, the patients response to the procedure and any follow up provided.

Upon patient record review, 3 of 14 (Patient #5,#7,#9) 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 5: The medical record includes documentation that the patient is at risk for seizures. There is no evidence that the aide plan of care includes seizure precautions. Patient 7: The medical record includes documentation that the patient is at risk for falls and aspiration. There is no evidence that the aide plan of care includes fall and aspiration precautions. Patient 9: The medical record includes documentation that the patient is at risk for falls and aspiration and requires oxygen precautions. There is no evidence that the aide plan of care includes fall, aspiration and oxygen precautions.

Upon patient record review 1 of 14 (Patient #5) 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 5:The aide plan of care includes the tasks of shower, shave, shampoo and partial bed bath scheduled weekly. The aide documentation notes the week of 12/1/24, the services of shower, shampoo, shave and partial bed bath were provided twice.

Upon patient record review, 5 of 13 (Patient #1, #2, #3, #8, #10) did not have evidence in the patient record that a complete review was performed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient #1- The medication profile includes Cyanocobalamin inj 1000mcg/ml 1000mcg injection every month. The orders are not specific for the actual route of injection. On 10/09/21 the nurse documents the patient is taking Tylenol. The medication profile does not include Tylenol. Patient #2- On 01/05/22 the medication profile was updated with Miralax 17 gm powder 1scoop daily for constipation. A diluent is not listed in the orders. Patient #3-On 01/20/22 the nurse documents the patient is to discontinue Eliquis. Eliquis was not discontinued from the medication profile. Patient #8-The medication profile includes Acetaminophen 325mg 2 tabs as directed po for fever or mild pain. (Frequency is not included). Patient #10- The medication profile includes Miralax 17 gm powder 1scoop daily po prn. A diluent and indications for prn is not listed in the profile.

Upon patient record review, 6 of 13 (Patient #4, #7, #8, #9, #10, #11) did not evidence in the patient record that the comprehensive assessment includes a bereavement component completed within the 5 days 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 #4-The patient was admitted 01/13/22 and a bereavement risk assessment was not performed until 01/20/22. Patient #7-The patient was admitted 12/23/21 and a bereavement risk assessment was not performed until 12/29/21. Patient #8-The patient was admitted 10/22/21 and a bereavement risk assessment was not performed until 10/29/21. Patient #9-The patient was admitted on 08/11/21 and a bereavement risk assessment was not completed until 08/20/21. Patient #10-The patient was admitted on 06/11/21 and a bereavement risk assessment was not completed until 06/23/21. Patient #11-The patient was admitted on 12/22/21 and a bereavement risk assessment was not completed until 12/28/21.

Upon patient record review, 8 of 13 (Patient #1, #2, #3, #4, #5, #8, #10, #11) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1- The 09/28/21 plan of care includes orders for Cyanocobalamin inj 1000mcg/ml 1000mcg injection every month. The orders are not specific for the actual route of injection. On 10/09/21 the nurse documents the patient is taking Tylenol. The plan of care was not updated to include Tylenol. Patient #2- The plan of care 12/09/21 includes orders for the nurse to instruct the patient on enteral feedings via gastrostomy tube. The orders are not specific for the type, amount, and delivery method for the feedings. The plan of care also does not include orders for maintenance of the tube with cleansing and dressing changes. On 01/05/22 the plan of care was updated with Miralax 17 gm powder 1scoop daily for constipation. A diluent is not listed in the orders. Patient #3- On 01/12/21 the nurse documents Benadryl cream was ordered due to the patients uncontrolled itching on back. The plan of care was not updated with the orders for Benadryl cream. On 01/20/22 the nurse documents the patient is to discontinue Eliquis. The plan of care was not updated with the orders to DC Eliquis. Patient #4- The patient was admitted with an ostomy and the plan of care does not address management of the ostomy. Patient #5-The 12/20/21 plan of care includes orders for an 18 Fr 5cc balloon Foley catheter to be changed monthly and prn. Indications for prn changes are not included in the plan of care. Patient #8-The 10/22/21 plan of care includes Acetaminophen 325mg 2 tabs as directed po for fever or mild pain. (Frequency is not included). Patient #10 The 12/08/21 plan of care includes Miralax 17 gm powder 1scoop daily po prn.. A diluent and indications for prn is not listed in the plan. Patient #11- On 12/29/21 an order was written to update the plan to cleanse wound with NS, apply Silvadene and dressing daily. The location of the wound is not specified in the order and the type of dressing change following Silvadene application is not specific.

Upon client record review, 1 of 13 (Patient # 1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1- On 10/08/21 the nurse documents the patient sustained an abrasion under the right cheek after a fall and the area was cleansed and a telfa dressing applied. There was no order for this wound care.

Upon patient record review, 5 of 13 (Patient #5, #6, #7, #10, #13) did not evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group and included in the plan of care. Patient #5-The aide is ordered to visit the patient 5 times weekly. The week of 12/26/21-01/01/22 the Aide visited three times on 12/28, 12/29 and 12/30/21. There is no documentation on record regarding the missed visits. Patient #6-The Aide was assigned to shave the patient weekly. The Aide documented a shave was not required on each of the visit notes on record between 12/20/21 and 01/27/22. Patient #7-The Aide is assigned to perform a bed bath twice weekly. Between 01/04/22 and 01/21/22 one bed bath was documented on 01/07/22. The other visits documented not required. Linen change was assigned weekly. Linen changes were not performed 01/04/22-01/21/22. Shampoo was assigned twice weekly. Between 01/04/22 and 01/21/22 one shampoo was documented on 01/07/22. All other visits documented a shampoo was not needed this visit. Patient #10-The aide is assigned to shower patient weekly. Between 12/17/21-1/12/22 the aide documented not required at this visit. Patient #13- The Aide is assigned to perform a shampoo on the days the patient receives a shower. A shower was documented on the following dates: 1/5, 1/11, 1/14, 1/18, 1/28 and 02/01/22 . The Aide documented a shampoo was not required on the same dates as the shower visits.

Upon patient record review, 1of 13 (Patient #5) did not evidence that each patient record contains a: • Signed election statement in accordance with 418.24 Patient #5-The date of election is blank on the signed hospice election statement.

Upon patient record review, 7 of 13 (Patient #1, #2, #3, #4, #5, #6, #7) did not evidence all entries are clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient #1-The visit notes on record 09/28/21-10/16/21 do not include the credentials of the staff members as part of the electronic signature. On 10/05/21 the nurse documents B12 injection was given in the right deltoid. The documentation is not specific for the dosage and route administered. On 10/11/21 the nurse documents the patients cheek dressing was performed per orders see care plan. The documentation is not specific for the actual wound care performed. Patient #2-The visit notes on record 12/9/21-01/27/22 do not include staff credentials . Patient #3- All visit notes on record 12/28/21-01/27/22 with the exception of a nursing visit on 12/29/21 do not include staff credentials . Patient #4- The 1/13/22 Nursing note, 01/14/22 Spiritual Care Provider note and the 01/20/22 Social Worker visit notes do not include employee credentials. Patient #5- The Spiritual Care Provider and Social Worker notes on record do not include employee credentials. Patient #6- The Social Worker notes on record do not include employee credentials. Patient #7- The following notes on record do not include employee credentials: Nursing visit notes on 01/05 and 01/07/22; Social Worker notes and Spiritual Care Provider notes.

Upon patient record review, 13 of 13 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13) did not evidence documentation in the medical record that the written policies and procedures for managing controlled drugs was provided and discussed.

Upon patient record review, 1 of 6 applicable (Patient # 8) 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 #8-The patient resides in a SNF. On 01/20/22 orders were written to cleanse the sacral wound with NS. Pat dry. Apply small amount of Medihoney to wound bed and cover with nonadherent pads. Change daily and prn if soiled. The orders do not specify whether the Hospice Nurse or Facility nurse is responsible for the dressing changes.