Every finding on record at Hosparus, Inc.

Based on interview and facility document review, the facility failed to protect the patients rights to voice complaints/grievances by failing to ensure the admission packet contained the correct number to the State Survey Agency to file a complaint/grievance. This deficient practice affected all patients who received care from the facility. The findings include: Review of the facility document titled, ";Care Guide," revised 12/2024, revealed ";This booklet was written to answer some of the questions people ask once they have chosen hospice services." Per the Care Guide, ";The Compliance Hotline: If you have concerns about patient care or safety, report your concerns to the Compliance Hotline at [telephone number]." On 01/27/2025 at 8:48 AM and 01/29/2025 at 11:14 AM, the Surveyor called the telephone number listed in the Care Guide and the telephone number was not in service. During an interview on 01/29/2025 at 1:20 PM, the Executive Director of Quality and Survey Excellence stated the number to file a complaint was listed in the admission packet (Care Guide). During an interview on 01/30/2025 at 2:45 PM, the Medical Director stated she would expect the admission packet to contain the correct telephone number for a patient to file a complaint.

Based on observation, interview, and facility policy review, the facility failed to ensure 2 (Registered Nurse [RN] #1 and RN #2) of 2 observed staff removed their gloves after disinfecting equipment and performed hand hygiene as per facility policy. Observation revealed Registered Nurse (RN) 1 and RN 2 they failed to remove their gloves after disinfecting their stethoscopes and failed to perform hand hygiene before they assessed a patients heart, lungs, and abdomen. The findings include: Review of the facility policy titled, ";Hand Hygiene" reviewed 08/19/2024, revealed, ";Hand hygiene is a general term used by the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) to refer to handwashing, antiseptic handwashing, antiseptic hand rubbing, and surgical hand asepsis." Per policy review, the hands were the conduits for almost every transfer of potential pathogens from one patient to another, from a contaminated object to a patient, and from a staff member to a patient. Continued review revealed because of this, hand hygiene was the single most important procedure to prevent infection and to protect patients from health care-associated infection, hand hygiene ";must be" performed routinely and thoroughly." Review revealed the policy specified, ";Washing with soap and water is appropriate when the hands are visibly soiled or contaminated with blood or other body fluids, when exposure to potential spore-forming pathogens is strongly suspected or proven, and after using the restroom." Further policy review revealed an alcohol-based hand rub was ";appropriate for decontaminating the hands: before direct patient contact, putting on gloves, or inserting an invasive device - when moving from a contaminated body site to a clean body site during patient care - after contact with a patient or with body fluids, excretions, mucous membranes, nonintact skin, or wound dressings (if hands arent visibly soiled) - after contact with inanimate objects in the patients environment - after removing gloves." During an observation on 01/28/2025 at 11:11 AM, RN #1 performed hand hygiene prior to the application of gloves. Per observation, RN #1 then obtained a stethoscope from a patients bedside table and disinfected the stethoscope with a disinfectant wipe. Further observation revealed while wearing the same gloves she wore to disinfect the stethoscope, RN #1 assessed the patients heart, lungs, and abdomen with the stethoscope, without removing the gloves and performing hand hygiene as required. During an interview on 01/28/2025 at 11:20 AM, RN #1 stated she had received infection control training regarding personal protective equipment had been received. RN #1 stated she was expected to remove the gloves she wore to disinfect the stethoscope, perform hand hygiene, and put on a clean pair of gloves before she assessed the patient. During an observation on 01/28/2025 at 11:43 AM, RN #2 performed hand hygiene, put on gloves, and administered intravenous medication to a patient. Continued observation revealed RN #2 then removed a stethoscope from around her neck and disinfected the stethoscope with a disinfectant wipe. Further observation revealed while wearing the same gloves she wore to disinfect the stethoscope, RN #2 assessed the patients lung with the stethoscope, without removing the gloves and performing hand hygiene as required. During an interview on 01/28/2025 at 12:00 PM, RN #2 stated she received training on infection control and was expected to remove her gloves and perform hand hygiene before she moved from a dirty task to a clean task.

Based on interview, record review, and facility policy review, the facility failed to ensure the family of 1 (Patient #6) of 3sampled patients sampled for bereavement received bereavement services after the patients death (Patient (P) 6). The findings include: Review of the facility policy titled, ";Grief Counseling Center-Services" effective 05/17/2022, indicated revealed, ";2. [Facility name] Grief Counseling Center provides anticipatory grief services, as well as bereavement services at no charge for up to thirteen months following a hospice patients death." Review of the facility policy titled, ";Bereavement-Mailings and Initial Contact," effective 01/01/2025, revealed, ";bereavement services were offered through mailings and telephone calls to family members, caregivers and significant others of deceased [facility name] patients. Per review, anyone identified by the interdisciplinary group as being at risk for complicated grief or as needing immediate attention by a bereavement counselor ";is contacted within 72 hours or three business days if prior to holiday or weekend by bereavement services." Continued review revealed the policy specified, ";4. Bereavement mailings (individualized letter with grief support handouts and current programming material) are sent at four weeks, three months and six months to anyone admitted to bereavement with correct mailing addresses." Review of the, ";Patient Information Report" revealed the facility admitted Patient #6 on 06/25/2020. According to additional review of the Patient Information Report, the patient expired on 06/26/2020. Review of #P6s medical record revealed no evidence to indicate a bereavement risk assessment, a phone call or the mailing of a bereavement letter had been completed for the patients family after the patients death. During an interview on 01/30/2025 at 9:39 AM, the Executive Director of Counseling Services stated a nurse or member of the interdisciplinary group would call a patients family after the death of a patient and, in a week after the patients death, the chaplain would offer the patients family bereavement services. The Executive Director of Counseling Services stated at one, three, and six month intervals, a letter would be mailed to the patients family. During an interview on 01/30/2025 at 5:25 PM, the Medical Director stated she expected the facility to send out information related to group services offered by the Grief Counseling Center to the patients families.

Based on observation, interview, and facility document review, the facility failed to ensure preventative maintenance of a blood pressure machine was conducted on a blood pressure machine. The failure to follow the equipments service manual instructions had the potential for equipment malfunction, which could negatively impact the safety and well-being of the 10 inpatient hospice patients who received care at the facility. The findings include: Review of the ";M3 Vital Signs Monitor Service Manual," dated 08/2008, revealed, ";Routine Check: The overall check of the monitor, including the functional safety check, must be performed by qualified personnel once every 6 to 12 months or each time after fixing up." Per review, all checks that were needed to open the monitor enclosure ";must" be performed by qualified service personnel. Further review revealed ";Warning: If the hospital or agency does not follow a satisfactory maintenance schedule when using monitor, the monitor may become invalid, and the human health may be endangered." Observation of the personal protective equipment (PPE) room on 01/28/2025 at 10:55 AM, revealed a blood pressure machine with no preventative maintenance sticker to indicate when preventative maintenance had last been performed on the machine. During an interview on 01/28/2025 at 11:05 AM, the Director of Inpatient Services stated she was unsure if preventative maintenance was required for the equipment. During an interview on 01/30/2025 at 9:17 AM, the Director of Facilities stated the facility had equipment that was used for patients that preventative maintenance had not been performed. The Director of Facilities stated the facility had no policies and procedures on preventative maintenance in place, and he was not sure what the expectation to perform it was. During an interview on 01/30/2025 at 5:05 PM, the Medical Director stated the expectation had always been that the facility followed the patient equipment manual for preventative maintenance.

Observed in Record Review. In 1 of 6 patient records reviewed, it was noted that the plan of care did not contain interventions related to Diabetes for a patient who was on blood sugar checks QID and documentation that the patient was eating candy bars. This was noted in record review #6. This was confirmed by the compliance nurse.

Observed in Record Review. In 1 of 20 patient records reviewed, the hospice did not conduct a patient specific comprehensive assessment/reassessment. In HV #1, the surveyor noted the nurse failed to assess the size of the wound every 14 days as required by the organization's procedural guideline. This was confirmed with the Clinical Compliance Risk Manager. Observed in Individual Tracer. In 1 of 5 home visits conducted, the hospice did not conduct a patient-specific comprehensive assessment/reassessment. In HV #2, the surveyor noted the patient was identified at risk for skin breakdown; however, the nurse failed to assess the patient's skin integrity to include all pressure points at the home visit as required by the organization's procedural guideline. This was confirmed with the Chief Medical Officer

Observed in Record Review. In 5 of 20 patient records reviewed, a bereavement risk assessment was not completed as part of the initial comprehensive assessment. In RR #1, RR #3, RR #4, RR #5 and RR #15, the surveyor noted the bereavement risk assessment was not completed as part of the comprehensive assessment on admission. This was confirmed with the Clinical Compliance Risk Manager.

Observed in Record Review. In 14 of 20 patient records reviewed, the plan of care was not based on the patient's goals and the time frames, settings and services required to meet those goals. In HV #1 and RR #2(GIP), the surveyor noted the plan of care included the following non-measurable medical social worker goal: patient/caregiver has decreased fear/anxiety regarding death and dying process. Patient's stress/anxiety is reduced to level of comfort. This was confirmed with the Clinical Compliance Risk Manager. In RR #1, the surveyor noted the plan of care included the following non-measurable goal: patient shortness of air will remain managed at desired level for next 7 days. This was confirmed with the Clinical Compliance Risk Manager. In RR #2(GIP), the surveyor noted the plan of care medical social worker and chaplain goals did not include time frames. This was confirmed with the Clinical Compliance Risk Manager. In HV #3, the surveyor noted the plan of care included the following non-measurable chaplain goals: Patient to experience spiritual support and companionship as evidenced by ongoing participation in CHP visitations and with patient's minister and church members. CHP to provide spiritual companionship and support of spiritual practices. This was confirmed with the Clinical Compliance Risk Manager. In HV #4, the surveyor noted the plan of care chaplain goals on the initial plan of care did not include time frames. This was confirmed with the Clinical Compliance Risk Manager. In RR #10, the surveyor noted the plan of care included the non-measurable pain goal: pain is currently managed at a level acceptable to patient. This was confirmed with the Clinical Compliance Risk Manager. In HV #5, RR #6, RR #8, RR #9, RR #10, RR #12, RR #13 and RR #15,, the surveyor noted the initial plan of care goals did not include time frames. This was confirmed with the Clinical Compliance Risk Manager.

Observed in Record Review. In 11 of 20 patient records reviewed, the plan of care did not include interventions to manage pain and symptoms. In HV #1, the surveyor noted the patient was identified as having constipation and at risk for skin breakdown; however, the initial plan of care did not include interventions to address these identified needs. This was confirmed with the Clinical Compliance Risk Manager. In RR #1, the surveyor noted the patient was identified as having ascites, constipation and poor appetite; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the Clinical Compliance Risk Manager. In HV #3, the surveyor noted the patient was identified as having fatigue, edema and shortness of breath on exertion; however, the plan of care did not include interventions. In addition, the patient was identified at risk for falls; however, the plan of care did not include interventions until the seventh day of service. This was confirmed with the Clinical Compliance Risk Manager. In HR #4, the surveyor noted the patient was identified as having diarrhea on admission comprehensive assessment; however, the plan of care did not include interventions to address this identified need. This was confirmed with the Clinical Compliance Risk Manager. In RR #4, the surveyor noted the patient was identified as having an active UTI with an antibiotic in use and constipation; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the Clinical Compliance Risk Manager. In RR #7, the surveyor noted the patient was identified as having shortness of breath, fatigue and ascites; however, the plan of care did not include interventions to address these identified needs. In addition, the patient developed constipation; however, the plan of care was not updated to address this identified need. This was confirmed with the Clinical Compliance Risk Manager. In RR #8, the surveyor noted the patient was identified as having dysphagia; however, the plan of care did not include interventions to address this identified need. This was confirmed with the Clinical Compliance Risk Manager. In RR #11 and RR #12, the surveyor noted the patient was identified as having anxiety; however, the plan of care did not include interventions to address this identified need. This was confirmed with the Clinical Compliance Risk Manager. In RR #13, the surveyor noted the patient was identified at risk for falls; however, the plan of care did not include interventions to address this identified need. This was confirmed with the Clinical Compliance Risk Manager. In RR #14, the surveyor noted the patient was identified as having anxiety, edema and at risk for falls; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the Clinical Compliance Risk Manager.

Observed in Record Review. In 4 of 20 patient records reviewed, the plan of care did not include a detailed statement of the scope and frequency of service necessary to meet the specific patient and family needs. In RR #10, the surveyor noted the plan of care visit frequency for skilled nursing was one time per week with 5 PRN visits: however, the patient was admitted with a pleurx drain, severe pain, nausea/vomiting and required four prn visits in the five days the patient was on service prior to expiring. The visit schedule did not meet the patient's identified needs. This was confirmed with the Clinical Compliance and Risk Manager. In RR #11, the surveyor noted the initial plan of care included intervention of hospice aide services; however, the patient did not receive aide services at home. This was confirmed with the Clinical Compliance Risk Manager. In RR #12, the surveyor noted the MSW changed visit frequency from one visit every three weeks to 4 visits every 2 week 2; however, the patient was seen every four weeks after the order so the visit frequency was inaccurate. This was confirmed with the Clinical Compliance Risk Manager. In RR #13, the surveyor noted the updated plan of care/IDG note included a plan and visit schedule for the chaplain; however, the chaplain had not seen the patient for an assessment of needs.. This was confirmed with the Clinical Compliance Risk Manager.

Observed in Record Review. In 13 of 20 patient records reviewed, the plan of care did not include drugs and treatment necessary to meet the needs of the patient. In all records reviewed, the surveyor noted the plan of care included interventions that were not individualized to the patient identified needs. For example, the plan of care included the following wound care orders for all patients; however, the patient did not have wounds: WOUNDS: WITH EACH DRESSING CHANGE, CLEANSE WOUNDS WITH APPROPRIATE WOUND CLEANSER. APPLY SKIN PREP/SEALENT TO PERIWOUND SKIN. FOR STAGE ONE PRESSURE ULCERS: APPLY BARRIER OINTMENT OR ZINC OXIDE PRODUCT DAILY. RELIEVE PRESSURE AREAS WITH REPOSITIONING/ELEVATION. FOR STAGE TWO PRESSURE ULCERS: DRY WOUNDS: APPLY HYDROGELABOUT 1/4 INCH DEEP. COVER WITH TRANSPAENT DRESSING. CHANGE EVERY 5 DAYS AND PRN SOILAGE. MINIMAL EXUDATE: APPLY HYDROCOLLOID OR NON ADHERENT DRESSING. CHANGE EVERY 5 DAYS AND PRN SOILAGE. MODERATE TO HEAVY EXUDATE: APPLY FOAM DRESSING OR CALCIUM ALGINATE AND COVER WITH SECONDARY DRESSING. CHANGE EVERY 3 DAYS AND PRN SOILAGE. FOR STAGE 3 AND 4 PRESSURE ULCERS: MINIMAL EXUDATE: HYDROCOLLOID / NON-ADHERNET/ OR FOAM DRESSING. CHANGE EVERY 5 DAYS AND PRN SOILAGE. MODERATE TO HEAVY EXUDATE: APPLY FOAM DRESSING OR CALCIUM ALGINATE AND COVER WITH SECONDARY DRESSING. CHANGE EVERY 3 DAYS AND PRN SOILAGE. DEEP WOUNDS / TUNNELING / UNDERMINING: LIGHT PACKING TO FILL SPACE. MOISTENED SALINE GAUZE FOR MINIMAL DRAINAGE. CALCIUM ALGINATE FOR MODERATE / HEAVY DRAINAGE. FOR UNSTAGEABLE WOUNDS: DRY INTACT ESCHAR: LEAVE ALONE. MAY PAINT WITH BETADINE Q DAY. ESCHAR WITH MINIMAL EXUDATE: APPLY GAUZE WITH TRANSPARENT DRESSING. CHANGE EVERY 3 DAYS AND PRN SOILAGE. MODERATE TO HEAVY EXUDATE: APPLY FOAM DRESSING OR CALCIUM ALGINATE AND SECONDARY DRESSING. CHANGE EVERY 3 DAYS AND PRN SOILAGE. FOR DEEP TISSUE INJURY: APPLY BARRIER CREAM TO AFFECTED AREA. OFF LOAD PRESSURE TO AREA. IF AREA OPENS, FOLLOW PRESSURE ULCER REGIMEN BASED UPON DEPTH. FOR SKIN TEARS: IF SKIN FLAP INTACT: REATTACH SKIN FLAP TO WOUND / USE STERI STRIPS AND COVER WITH NON ADHERENT DRESSING. SECURE WITH PAPER TAPE OR ROLLED GAUZE. CHANGE EVERY 5 DAYS OR PRN SOILAGE. APPLY ANTIBIOTIC OINTMENT OR VASELINE TO KEEP MOIST IF NEEDED. IF SKIN FLAP MISSING: COVE WITH NON ADHERENT DRESSING AND SECURE WITH PAPER TAPE OR ROLLED GAUZE. CHANGE EVERY 5 DAYS OR PRN SOILAGE. APPLY ANTIBIOTIC OINTMENT OR VASELINE TO KEEP MOIST IF NEEDED. FOR WOUNDS WITH FOUL ODOR: OPTION ONE (USE FIRST): MEDICAL HONEY: APPLY THIN LAYER TO WOUND BED WITH EACH DRESSING CHANGE. COVER WITH DRESSING BASED UPON AMOUNT OF DEPTH / DRAINAGE AMOUNT OF WOUND. OPTION TWO: (USE ONLY IF OPTION ONE DOES NOT IMPROVE WOUND IN 30 DAYS) FLAGYL TABLETS 250 MG SPRINKLE 1-2 CRUSHED TABS IN WOUND BED ONCE A DAY. COVER WITH DRESSING BASED UPON AMOUNT OF DEPTH / DRAINAGE AMOUNT OF WOUND. OPTION3 (USE ONLY IS OPTION 1 AND 2 DO NOT IMPROVE WOUND IN 60 DAYS) DAKIN'S 1/4 STRENGTH: WET TO MOIST DRESSING BID. PACK WOUND WITH MOISTENED GAUSE AND COVER WOUND WITH ABD PADS. FOR WOUNDS NEEDING DEBRIDEMENT: OPTION 1: MEDICAL HONEY: APPLY THIN LAYER TO WOUND BED WITH EACH DRESSING CHANGE. COVER WITH DRESSING BASED UPON AMOUNT OF DEPTH / DRAINAGE AMOUNT OF WOUND. FOR OTHER ULCER TYPES: FOLLOW PRESSURE ULCER PROTOCOL. CHOICE OF DRESSINGS WILL BE DEPENDENT UPON AMOUNT OF EXUDATE AND DEPTH OF WOUND. In addition, the interventions included interventions for urinary catheterization although the patient was not identified as having urinary retention: URINARY RETENTION: (REQUIRED) BLADDER CATHETERIZATION AS NEEDED: FOR FEMALE PATIENTS - USE #16 FOLEY WITH 10ML BALLOON. IF UNSUCCESSFUL MAY USE #18 FOLEY WITH 10 ML BALLOON. PLACE FOLEY TO BEDSIDE DRAINAGE. FOR MALE PATIENTS - USE #16 COUDE CATHETER WITH 10ML BALLOON. IF UNSUCCESSFUL MAY USE #18 COUDE CATHETER WITH 10 ML BALLOON. PLACE COUDE CATHETER TO BEDSIDE DRAINAGE. This was confirmed with the Clinical Compliance Risk Manager. In HV #2, the surveyor noted the plan of care medications included hydrochlorothiazide prn; however, the order did not specify an indication of when to initiate the order. This was confirmed with the Clinical Compliance Risk Manager. In RR #1, the surveyor noted the patient was identified as having a rash to the PEG tube site and CPAP at night.; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the Clinical Compliance Risk Manager. In RR #2(GIP), the surveyor noted the nurse documented foley catheter was inserted; however, the plan of care order indicated insert foley catheter 14 - 16 French with no change frequency or size of balloon. This was confirmed with the Clinical Compliance Risk Manager and Chief Medical Officer. In RR #3, the surveyor noted the plan of care medication orders included three prn medications for constipation (Colace, milk of magnesia and miralax); however, the instructions did not specify when to take which medication. This was confirmed with the Clinical Compliance Risk Manager. In RR #4, the surveyor noted the skilled nurse was weighing the patient at each visit; however, the plan of care did not include this intervention. This was confirmed with the Clinical Compliance Risk Manager. In RR #5, the surveyor noted the patient was receiving tube feeding; however, there was no intervention on the plan of care related to the type of tube feeding, volume, and free water until 6 weeks after start of care. In addition, the patient was having blood sugar monitored; however, the plan of care did not include this intervention. Also, the patient had a g-tube; however, the plan of care did not include site care. Lastly, the plan of care included PRN medications for seizures to include clonazepam and versed; however, the instructions did not specify which one to give first. This was confirmed with the Clinical Compliance Risk Manager. In RR #7, the surveyor noted the patient used a CPAP; however, the plan of care did not include this intervention. In addition, the organization had a standing order for foley catheter insertion for urinary retention; however, the nurse inserted a foley catheter for patient comfort so patient did not have to get out of bed without obtaining a physician order. This was confirmed with the Clinical Compliance Risk Manager. In RR #9, the surveyor noted the patient was identified as having a UTI and had pressure ulcers; however, the plan of care did not include interventions to address the UTI or the wound care. This was confirmed with the Clinical Compliance Risk Manager. In RR #10, the surveyor noted the plan of care included prn orders for Zofran and Haldol for nausea/vomiting; however, the instructions did not specify when to take which medication. This was confirmed with the Clinical Compliance Risk Manager. In RR #11, the surveyor noted the patient was identified as having colostomy, abdominal wound, PEG tube site; however, the plan of care did not include interventions to address these identified needs to include colostomy care, wound care and PEG tube site care and tube feeding. In addition, the patient was on insulin to include sliding scale; however, the plan of care did not include blood sugar monitoring. This was confirmed with the Clinical Compliance Risk Manager. In RR #12, the surveyor noted the patient was identified as having colostomy, abdominal wound, PEG tube site; however, the plan of care did not include interventions to address these identified needs to include colostomy care, wound care and PEG tube site care and tube feeding. In addition, the patient was on insulin to include sliding scale; however, the plan of care did not include blood sugar monitoring. This was confirmed with the Clinical Compliance Risk Manager. &#x

Observed in Record Review. In 4 of 20 patient records reviewed, the organization did not provide the patient with care, treatment or services according to the patient's individualized plan of care. In HV #4, the surveyor noted the visit the aide visit frequency on the plan of care was two times per week; however, there was a missed aide visit the sixth week of the second certification period and no documentation of RN notification. This was confirmed with the Clinical Compliance Risk Manager. In RR #6, the surveyor noted there was a missed aide visit the third week of service; however, there was no documentation of RN notification of the missed visit. This was confirmed with the Clinical Compliance Risk Manager. In RR #7, the surveyor noted the aide visit frequency was 2x's per week; however, there were no aide visits made the third week of service. In addition, the patient was to be seen twice per week by the skilled nurse; however, there were no scheduled visits made the fifth week of service until a prn visit was made for end of life on Friday and Saturday of that week. The chief medical officer reported that there was a missed scheduled visit on the Tuesday of that week with no documentation of a missed visit. This was confirmed with the Clinical Compliance Risk Manager. In RR #12, the surveyor noted the aide visit frequency was 2 x's per week ; however, the patient was seen only one time per week the fourth and fifth week of service. In addition, there was a missed skilled nursing visit the third week of service; however, there was no documentation of a missed visit. This was confirmed with the Clinical Compliance Risk Manager.

Observed in Individual Tracer. In 2 of 5 home visits conducted, the organization did not use standard precautions to reduce the risk of infection. In HV #2, the surveyor noted the nurse touched the patient and then went into the clinical bag without performing hand hygiene as required by the organization's procedure. This was confirmed with the Chief Medical Director. In HV #4, the surveyor noted the aide doffed gloves after cleaning upper body and then donned new gloves without performing hand hygiene. This was discussed with the Vice President of Compliance.

Observed in Record Review. In 7 of 13 patient records reviewed where the patient received aide services, a registered nurse did not prepare written patient care instructions for the hospice aide. In HV #4, RR #10, RR #12 and RR #13, the surveyor noted the aide plan of care did not include fall precautions. This was confirmed with the Clinical Compliance Risk Manager. In RR #4, the surveyor noted the aide plan of care did not include fall precautions or oxygen instructions. This was confirmed with the Clinical Compliance Risk Manager. In RR #6, the surveyor noted the aide plan of care did not include fall precautions or swallowing precautions. This was confirmed with the Clinical Compliance Risk Manager. In RR #7, the surveyor noted the aide plan of care did not include fall precautions or seizure precautions. This was confirmed with the Clinical Compliance Manager.

Observed in Record Review. In 1 of 13 patient records reviewed where the patient received aide services, the hospice aide did not provide services as ordered in the aide plan of care. In RR #6, the surveyor noted the wife refused the bed bath; however, the nurse was not notified of the refusal of care. This was confirmed with the Clinical Compliance Risk Manager.

Observed in Individual Tracer. In 1 of 5 home visits conducted, the patient record did not contain an accurate medication list. In HV #5, the surveyor noted the medication profile included alendronate; however, the patient's sister reported this medication was discontinued one month ago. This was confirmed with the Vice President of Compliance. Observed in Record Review. In 2 of 20 patient records reviewed, the patient record did not contain all clinical information. In HV #5, the surveyor noted the patient fell the third month of service; however, the nurse failed to document the physician notification. This was corrected at the time of survey. This was confirmed with the Clinical Compliance Risk Manager. In RR #12, the surveyor noted a telehealth visit made on the sixth week of service by the skilled nurse; however, the note did not specify why the visit was made by telehealth as indicated in the emergency plan protocol. This was confirmed with the Clinical Compliance Risk Manager.

Observed in Building Tour. The surveyor noted in the east and north hallways the integrity of the means of egress was not maintained as evidenced by the organization stored CNA carts in the hallway that were maintained in the same location for an entire shift. This was confirmed with the Hospice Inpatient Manager. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.