Every finding on record at Hospice of the Emerald Coast, Inc.

Upon patient record review 1 of 27 (Patient #13) did not have evidence that the hospice Registered Nurse must complete an initial assessment within 48 hours after the election of hospice care in accordance with §418.24 Patient#13: The record indicated that the election of benefit states effective date 8/8/23. The election of benefit form was signed and dated 8/8/24. There is no evidence RN initial assessment performed within 48 hours of 8/8/2023.

Upon patient record review 1 of 27 (Patient #13) 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#13: The record indicated that the election of benefit states effective date 8/8/23. The election of benefit form was signed and dated 8/8/24. There was no evidence psychosocial and spiritual assessment completed within 5 days of 8/8/23.

Upon patient record review 1 of 27 (Patient #4) 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#4: There is no evidence of an initial spiritual assessment being completed.

Upon patient record review, 1 of 27 (Patient #11) 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#11: The record indicates on 4/23/25 ketoconazole 2% apply 1 cm 2 times a day. However, there was no specified area of application indicated. The medication profile was update with location in order to correct on site.

Upon patient record review, 5 of 27 (Patient #1,#3,#11,#16,#17) 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: The record indicates the patient takes valproate 500mg/5ml 4 times a day for seizures. There is no evidence of seizure precautions on care plan. The record also indicates the patient has a PEG tube. There is no indication of goals and interventions regarding specific PEG tube care and flushes. The care plan was updated in order to correct on site. Patient#3: The record indicates seizure precautions are indicated on the aide plan of care. There is no evidence of seizure precautions on care plan. The Care plan was updated in order to correct on site. Patient#11: The record indicates seizure precautions, aspiration precautions, and oxygen safety/precautions are on the aide plan of care. There is no evidence of these precautions on care plan. This was updated in order to correct on site. Patient#16: The record indicates aspiration precaution are indicated on the aide plan of care. There is no evidence of this precaution on the care plan. This was updated in order to correct on site. Patient#17: The record indicates fall precaution are indicated on the aide plan of care. There is no evidence of this precaution on the care plan. This was updated in order to correct on site.

Upon patient record review, 2 of 27 (Patient #1,#11) 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: There was no evidence of an order for PEG tube care and flushes. An appropriate order was entered in order to correct on site. Patient#11: The record indicates on 4/23/25 ketoconazole 2% apply 1 cm 2 times a day. However, there was no specified area of application indicated. The order was update with location in order to correct on site.

Upon patient record review 1 of 27 (Patient #4) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient#4: The record indicates patient had an X-ray on 6/19/25 after a fall. The family called triage on 6/21 requesting results and was told the results had not yet been received. There was no evidence of results being received or any further follow up with X-ray company or patient. The agency obtained and uploaded the X-ray results and entered a coordination note.

Upon patient record review, 6 of 27 (Patient #1,#5,#7,#8,#9,#16,#19#20) 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#1: There is no evidence of fall precautions, aspiration precautions, or seizure precautions on aide plan of care. Also, there was no notification or mention that patient had PEG tube on aide plan of care. In order to correct on site, these needs were added to aide plan of care. Patient#5: The record indicates the aide frequency was ordered as 4 times per week. However, this order is unclear as documentation shows 2 aides going together 2 times per week. A new order was written with frequency of 2 aides to visit 2 times per week for a 2 person assist. Patient#7: The record indicates bleeding precautions are on the patient care plan. However, there is no evidence of this on the aide plan of care. This was added in order to correct on site. Patient#8: There is evidence that wheelchair, oral care, and nail care on the aide plan of care are assigned "every visit as needed". In order to correct on site the aide plan of care was updated and as needed was removed. Patient#9: There is evidence that the shower task is assigned" every visit per patient request assist with getting into shower" on aide plan of care. This was corrected on site by updating to " every visit stand by assist". Patient#16: The record indicates bleeding precautions are indicated on the plan of care. There is no evidence of this on the aide plan of care. This was added to aide plan of care in order to correct on site. Patient#19: The record indicates fall precautions are indicated on the plan of care. There is no evidence of this on the aide plan of care. This was added to aide plan of care in order to correct on site. Patient#20: The record indicates the aide frequency was ordered as 4 times per week. However, this order is unclear as documentation shows 2 aides going together 2 times per week. A new order was written with frequency of 2 aides to visit 2 times per week for a 2 person assist.

Upon patient record review 2 of 27 (Patient #10,#17) 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#10: The record indicates the aide's first visit to patient was on 6/19/25. There is no evidence of an aide supervisory visit being performed from 6/19 to present. The agency did completed an aide supervisory visit during survey on 7/9/25. Patient#17: There is no evidence of an aide supervisory visit completed between 5/22/25 and 6/23/25.

Upon patient client record review, 1 of 27 (Patient #13) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient#13: The record indicated that the election of benefit states effective date 8/8/23. The election of benefit form was signed and dated 8/8/24.

Upon patient client record review, 2 of 27 (Patient #5,#6) 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#5: The aide plan of care indicates patient has an amputation. There is no evidence in patient chart of an amputation. This was documented in error and removed from the aide plan of care in order to correct on site. Patient#6: Upon review of record evidence showed that RN narrative on 7/1/25 and 6/27/25 were the exact same. This was also found for RN narrative on 6/13 and 6/22.

Upon client record review, 1 of 27 (Patient #6) 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#6: The care plan indicates there is an intervention for SN to assess PICC line dressing at every visit. There is no evidence of documentation that this was completed from 5/20/25-7/3. Documentation indicates the facility removed the PICC line on 7/3/25.

Upon patient record review 2 of 19 applicable records (Patient #1,#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 #1: The patient was admitted on 5/3/22. The record indicated that the spiritual assessment was completed on 5/13/22. Patient #9: The patient was admitted on 4/28/22. The record indicated that the spiritual assessment was completed on 5/19/22.

Upon patient record review 1 of 20 (Patient #18) did not have evidence in the patient record that the comprehensive assessment identifies the spiritual needs related to the terminal illness. Patient #18: There was not evidence of a spiritual assessment.

Upon patient record review, 12 of 20 records (Patient #1,#3,#4,#6,#7,#8,#10,#11,#12,#16,#19,#20) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient #1: The nurse documentation indicated that oxygen was ordered and that the patient was using it intermittently at 2-3L/min. There was not evidence that oxygen was a part of the medication profile. Corrected on site. Patient #3,6,7,20: There was an order for Miralax 17Gm oral powder-packet daily without evidence of a diluent. Current patients corrected on site. Patient #4: The record indicated for Lidocaine topical patch 3.5%, 1 patch TID. Lidocaine topical patches are typically applied 1 patch topically to affected area of intact skin for up to 12 hours a day (Not 3x/day). There was also not a specific area or location. In addition, the medication profile included for eye drops irritation relief, follow instructions on bottle. There was not evidence of instructions. Also Oxygen 2L/min as needed for shortness of breath. There was not evidence of a route. Plus Voltarin was listed in duplicate without evidence of a specific location to apply the medication. They included Voltarin 1% topical 4x daily prn to affected area and Voltarin arthritic gel. Apply thin layer to affected area TID. All corrected on site. Patient #8: The medication profile contained Juven with Collagen, 1 powder in packet 2x daily G-tube. There was not evidence of a diluent. Corrected on site. Patient #10: The record indicated oxygen at 2L/min continuously. During the visit, the patient was not wearing oxygen, indicated that he had not used the oxygen, and the oxygen concentrator was covered with the plastic protective covering. Corrected on site. Patient #11: The record indicated O2 at 2L/min via nasal cannula. For the month of June to current, nurse notes indicated 2L/min on some documentation and 3L/min on some documentation. There was not evidence of a change in the litter flow to 3L/min. Corrected on site. Patient #12: The record indicated Insulin Aspart U-100 SQ inject per instructions. Administer per sliding scale. There was not evidence of the sliding scale. Corrected on site. Patient #16: The medication profile indicated for 2 different orders for Lorazepam. They included Lorazepam 0.5mg q4h and Lorazepam 0.5mg qh4 prn. There was not evidence of a maximum allowable dose/24h period in the order. Corrected on site. Patient #19: The record indicated an order dated 2/9/22 for SSD 1% topical cream, apply to affected area daily. There was not evidence of a specific area for the application. In addition, an order for Lidocaine 5% topical ointment, dated 2/9/22, 1 time daily as needed to affected area. There was not evidence of a specific location for application. Also, Lidocaine-Pilocarpine 2.5%-2.5% (Dated 2/9/22), as directed, as needed. There was not evidence of a time frequency or a specific application area. And, O2 at 3L/min continuously without evidence of a route.

Upon patient record review, 2 of 20 records (Patient #8,#18) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component. Patient #8: The patient was admitted on 4/19/22. The record indicated that the bereavement assessment was completed on 6/6/22. Patient #18: There was not evidence of a bereavement risk assessment.

Upon patient record review, 1 of 20 records (Patient #19) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient that reflects patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. Patient #19: The patient was admitted with a diagnosis of malignant neoplasm of the vulva. The record indicated that the patient was having episodes of increased pain whereby on 3/10/22 Fentanyl was increased and Morphine was started. Also on 3/17/22, both Fentanyl and Morphine was increased. There was not evidence of care plan problem for pain with related goals.

Upon patient record review, 11 of 20 records (Patient #1,#3,#4,#6,#7,#8,#11,#12,#16,#19,#20) 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 nurse documentation indicated that O2 was ordered and that the patient was using it intermittently at 2-3L/min. There was not evidence of an order for O2. Corrected on site. Patient #3,6,7,20: There was an order for Miralax 17Gm oral powder-packet daily without evidence of a diluent. Current patients corrected on site. Patient #4: The record indicated for Lidocaine topical patch 3.5%, 1 TID. Lidocaine topical patches are typically applied 1 patch topically to affected area of intact skin for up to 12 hours a day (Not 3x/day). There was also not a specific area or location. Also, there was an order for eye drops irritation relief, follow instructions on bottle. There was not evidence of instructions in the order. Also O2 @ 2L/min as needed for SOB. There was not evidence of a route. Voltarin was listed in duplicate without evidence of a specific location. The orders were Voltarin 1% topical 4x daily prn to affected area and Voltarin arthritic gel. Apply thin layer to affected area TID. All corrected on site. Patient #8: The record indicated an order which contained Juven with Collagen, 1 powder in packet 2x daily G-tube. There was not evidence of a diluent. In addition, the record indicated O2 at 2L/min continuously. During the visit, the patient was not wearing O2, he indicated that he had not used the oxygen and the oxygen concentrator was covered with the plastic protective covering. Corrected all on site. Patient #11: The record indicated oxygen at 2L/min via nasal cannula. For the month of June to current, the nurse notes indicated 2L/min on some documentation and 3L/min on some documentation. There was not evidence of an order for a change in the litter flow to 3L/min. Corrected on site. Patient #12: The record indicated Insulin Aspart U-100 SQ inject per instructions. Administer per sliding scale. There was not evidence of orders for the sliding scale. Corrected on site. Patient #16: The medication profile indicated for 2 different orders for Lorazepam. They included Lorazepam 0.5mg q4h and Lorazepam 0.5mg qh4 prn. There was not evidence of a maximum allowable dose/24h period in the order. Corrected on site. Patient #19: The record indicated an order dated 2/9/22 for SSD 1% topical cream, apply to affected area daily. There was not evidence of a specific area for the application. In addition, an order for Lidocaine 5% topical ointment, dated 2/9/22, 1 time daily as needed to affected area. Also, Lidocaine-Pilocarpine 2.5%-2.5% (Dated 2/9/22), as directed, as needed. There was not evidence of a time frequency or a specific application area. And, O2 at 3L/min continuously without evidence of a route.

Upon patient record review, 1 of 20 records (Patient #18) did not have evidence the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #18: The plan of care indicated that there were 'none' under the area requiring the listing of DME. The record revealed that the patient was on continuous oxygen, used nebulizers and had a trilogy ventilator.

Upon client record review, 2 of 16 applicable records (Patient #10, #12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #10: Upon observed home visit and record review, there was a notation and observation of wounds on the patient's right posterior knee and right elbow which required wound care. The skilled nurse provided wound care to both areas during the visit. There was not evidence of an order. Corrected on site. Patient #12: The social work visit frequency was every 2m2, 1m1 effective 5/12/22. The record indicated that visits were conducted on 5/13/22 and 6/17/22. In addition, the visit frequency for the spiritual care counselor was 1 every 2m2, 1m1. The record indicated that visits were conducted on 5/13/22 and 6/24/22.

Upon observation, there was not evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #10: The staff member was observed placing dirty dressings as well as clean dressings on the floor without a protective barrier.

Upon patient record review, 5 of 15 applicable records (Patient #2,#10,#14,#15,#16) 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 • Specific written patient care instructions for a hospice aide including precautions, that 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 Patient #2:The record indicated that the patient was on Eliquis. There was not evidence that the aide plan of care included bleeding precautions. (Shave patient every visit was ordered in the care plan). Corrected on site. Patient #10: The record indicated that the patient was a fall risk, had 1-2 falls in the past 3 months including a fall on 7/12/22. There was not evidence of fall precautions in the aide plan of care. Corrected on site. Patient #14: Nurse documentation in routine notes and IDG indicate that the patient is a fall risk and has had frequent falls. There was not evidence of fall precautions on the aide plan of care. Corrected on site. Patient #15: The certification of terminal illness indicated that the patient has a history of falls including a spinal fracture related to falls. There was not evidence of fall precautions on the aide plan of care. Corrected on site. Patient #16: The certification of terminal illness indicated that the patient has a history of multiple falls and had sustained 2 fractured hips as a result of falls. There was not evidence of fall precautions on the aide plan of care. Corrected on site.

Upon patient record review 2 of 15 applicable records (Patient #8,#14) 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 Patient #8: The aide visit frequency was 2x/week effective 5/15/22. For the week of 6/12/22-6/18/22, the record indicate only 1 visit on 6/13/22. Patient #14: The aide visit frequency was 1w1, 2w12. There was not evidence of visits or missed visit documentation until 4/19/22, no visits from 4/24/22 to 4/30/22, and only 1 visit for the week 5/1/22-5/7/22 and only 1 missed visit note for each of the weeks beginning 6/26/22 and 7/3/22.

Upon personnel record review, 1 of 1 applicable record (Personnel #2) did not have evidence the alternate administrator's personnel record verifies that: • There is a signed job description for this role • The employee has been orientated to this role Corrected on site.

Upon patient client record review, 2 of 20 records (Patient #12,#16) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #12,#16: The record indicated that the patient/representative wished to receive the “Patient Notification of Hospice Non-Covered Items, Services, and Drugs.” There was not evidence that this document was furnished.

Upon client record review, 1 of 4 applicable records (Patient #8) 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 #8: The skilled nurse visit frequency was 2x/week effective 5/12/22. For the weeks of 5/22/22 and 6/5/22, the record indicated 3 visit were conducted each of these weeks. In addition, the social work visit frequency was for an evaluation then 1 every 2m2, 1m5. The record indicated that the evaluation was conducted on 4/21/22 and subsequent visits were conducted on 5/4/22 and 6/2/22. Also the spiritual care counselor visit frequency was for an evaluation then 2 every 2m2, 2m1, 1m1. The record indicated that an evaluation was conducted on 4/21/22 and subsequent visits were conducted on 5/16/22, 5/27/22, 6/15/22, and 6/29/22.

Upon client record review, 1 of 4 applicable records (Patient #7) 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 #7: The record contained an order for wound care dated 4/25/22 for skin prep to suspected deep tissue injury right heel once daily. Wound care may be completed by hospice nurse of facility nurse. The order did not specifically identify who was to provide the wound care. Corrected on site.

Upon patient record review, 2 of 2 applicable records (Patient #2,#3) did not have evidence that the hospice provided the following information: • Hospice election form • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice's 24-hour on-call system Corrected on site.