Every finding on record at Holy Saver Hospice, Inc.

Observed in Record Review. In 1 of 14 patient records reviewed, the hospice surveyor observed that the Initial bereavement assessment was not completed per organizational policy. In the Bereavement Policy 2-010.1 it stated that bereavement services will be provided to the family and caregivers of hospice patients at the time of admission. In HOSRRHV #1 the son was the patient's representative and a bereavement assessment was not completed. This was reviewed and validated with the Director of Nursing.

Observed in Record Review. In 14 of 14 patient records reviewed, the hospice surveyor observed that the organization had not ensured that the goals established on the plan of care included measurable and individualized outcomes as required by regulation. In HOSRRHV #1, #2, #3, HOSRRNHV #1, #2, #3, HOSRRDC #1, #2, #3, #4 and HOSRRBRV #1, #2, 3, and 4 the MSW care plans all stated, Pt will have a sense of autonomy and PCG /Family will receive emotional and psychosocial support and will accept impending changes to the patient and family system within the recertification period. This goal was not individualized or measurable. The Chaplain care plan for each patient was the same and stated, Chaplain PCG and family will receive spiritual support from its faith community within the next recertification period. In HOSRRHV #1, #2, #3, HOSRRDC #1, #2, #3, #4, and HOSRRBRV #3, and #4 the RN care plan goal stated,Patient will remain free from pain or maintain pain within the patient's tolerable level (SIT=2/10) within 48 hours of admission. These patients did not have a defined SIT goal assessed. The care plan was not individualized with the patients acceptable pain goal. This was reviewed and validated with the Director of Nurses.

Observed in Patient Home. In 8 of 14 patient records reviewed, the hospice surveyor observed that duplicate medications were ordered and the indication for use was not clear. In HOSRRHV #1 the patient had orders for Acephen 650 mg rectal suppository every 6 hours as needed for pain, Acetaminophen 500 mg 2 tablets by mouth evey 8 hours as needed for pain, and Morphine Sulfate 20mg/ml every 2 hours as needed for pain. It is not clear when the patient should take one medication over the other. In HOSRRDC#1 the patient had orders for Acephen 650 mg rectal suppository every 6 hours as needed for pain, Morphine Sulfate 15 mg extended release 15 mg one tablet every12 hours for pain, and Morphine Sulfate 20 mg/ml every 2 hours as needed for pain. It is not clear when the patient should take one medication over he other for pain. In HOSRRDC #2 the patient had orders for Hydrocodone Bitartrate/Acetaminophen 10 mg-325 mg 1 tablet every 4 hours as needed for pan, Morphine Sulfate 15 mg ER 1 tablet every 12 hours for pan, and Morphine Sulfate 20 mg/ml every 2 hours as needed for pain. It is not clear when the patient should take one medication over the other for pain. In HOSRRBRV #1 the patient was taking MS 20 mg/1 ml every hour for pain and Acephen 650 mg rectal suppository 1 every 6 hours as needed for pain. It is not clear when the patient should take one medication over he other for pain. In HOSRRBRV #2 the patient was taking MS 20 mg/ml every 2 hours as needed for pain and Acephen 650 mg rectal suppository every 6 hours as needed for pain. It is not clear when the patient should take one medication over the other for pain. In HOSRRNHV #1 the orders stated BG checks twice a day before breakfast and dinner and call if BS <70 or >350. The patient had been on service for 6 weeks and there were no blood sugars entered into the record. In HOSRRNHV #3, the blood sugar order stated daily blood sugars before meals. There was no documentation for 9 months in the chart that the blood sugars were taken. In HOSRRDC #4 the order for blood sugar checks read, once a day in the morning and as needed for s/s of hypo/hyperglycemia. Patient was on service for 1 week and had two visits and no blood sugars were taken or entered into the visit note. This was reviewed and validated with the Director of Nurses.

Observed in Record Review. In 3 of 14 patient records reviewed, the aide care plan did not include specific precautions. In HOSRRHV #1 and HOSRRDC #4 the patient was on oxygen and the aide assignment did not give instructions on what the aide should do with the oxygen when bathing the patient. In HOSRRDC #2 the patient was on Oxygen and had a nephrostomy tube and the aide assignment did not instruct the aide what to do with the oxygen when bathing the patient and it also did not give parameters for the dressing on the nephrostomy tube. This was reviewed and validated with the Director of Nursing.

Observed in Patient Home. In 1 of 3 home visits conducted, the hospice surveyor observed that the medication list was discovered to be inaccurate. In HOSRRHV #2 per the patient's daughter the patient was taking Bactrim DS 350 mg one tablet on Monday, Wednesday, and Friday since November 2025, this medication was not on the medication list. The patient had Lorazepam 20 mg one tablet as needed for anxiety but per the daughter the patient was not taking this medication and it had not been provided by the organization. This was reviewed and validated with the Director of Nurses.

Observed in Patient Home. In 1 of 3 home visits conducted, the hospice failed to make DME available to the patient. In HOSRRHV #1 the organization did not exchange out an oxygen concentrator that was placed just prior to the start of hospice care in November 2025 by a non-contracted DME. company. This was reviewed and validated with the Director of Nurses.

Observed in Record Review. In 2 of 14 patient records reviewed, the hospice surveyor observed that there was no education provided on oxygen safety. In HOSRRHV #3 the patient had an order for Oxygen at 2 liters via nasal cannula as needed for shortness of breath, the hospice surveyor asked the daughter how much oxygen the patient normally gets and she could not give a number for the oxygen dosing. The hospice surveyor asked the daughter if the patient used the oxygen and she stated that she did but she could not tell the surveyor the ordered amount. In HOSRRDC #4 the nurse documented in the oxygen safety assessment that there were smoking materials in the home, and the patient was not 10 feet from open flames. There was no documentation of educating the patient on the dangers of these issues with oxygen therapy. This was reviewed and validated with the Director of Nurses.

Observed in Record Review. In 5 of 11 patient records reviewed, the plan of care did not include a statement of the scope and frequency of the services necessary to meet the patient’s and family’s needs. In HV #2, HV #3, RR #1, RR #5 and RR #6, the plan of care did not include the number or indication for why the SN prn visits would be made. For example, the order for SN was 1 time every 14 days and as needed. In HV #2 and RR #1, the Spiritual Counselor order was one time per month and as needed to address spiritual needs. This was jointly reviewed in the EMR and discussed with the Alternate Director of Patient Care Services.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not implement infection prevention and control activities when doing the following: Cleaning and performing disinfection of medical supplies and devices. In HV #1, the RN was observed cleaning vital sign equipment with Good Clean disinfectant wipes. She did not wait the required 4 minute wet/dry time prior to placing the equipment back into the zip lock bag and into the nursing bag. This was discussed with the RN and the Alternate Director of Patient Care Services..

Observed in Individual Tracer. In 1 of 7 patient records reviewed, with hospice aide services, the registered nurse who is a member of the interdisciplinary group and is responsible for hospice aide supervision did not prepare written patient care instructions for the hospice aide. In HV # 3, the hospice aide care plan was created 5 months ago at the time of admission and did not include updates and changes in patient condition. The care plan stated patient was continent and oriented. During the home visit the LVN and patient family described patient as very confused and incontinent. The Surveyor observed the patient was wearing an incontinence brief. There were no instructions on the aide care plan to provide incontinence care or to change the brief. This was discussed with the Alternate Director of Patient Care Services.

Observed in Record Review. In 1 of 7 patient records reviewed, with hospice aide services, the registered nurse did not supervise the hospice aide during an on-site visit to the patient’s home no less frequently than every 14 days. Upon review of documentation in the record, in RR #3, hospice aide services were provided for 39 days but no supervisory visit was documented. This was discussed with the Alternate Director of Patient Care Services. The RN corrected the documentation while the Surveyor was on site explaining she performed the supervision but failed to document it.